Every finding on record at Spalding Post Acute LLC

Based on observations, staff interviews, record review and review of the facility's policies titled Handwashing/Hand Hygiene, and Infection Prevention and Control Program, the facility failed to implement infection control protocol for two residents (R) (R34 and R82) of 14 residents observed for infection control. Specifically, nurse did not sanitize hands between glove change and nurse placed a tablet in her bare hand. The deficient practice increased the risk of cross contamination and the spread of infection to residents and staff. Findings include:Review of the facility's policy titled Handwashing/Hand Hygiene undated, documented Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. After removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.Review of the facility's policy titled Infection Prevention and Control Program reviewed 03/02/2025, documented Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.1.Review of the facility's electronic medical records (EMR) documented R82 was admitted to the facility 01/29/2024 with diagnosis included but not limited to diabetes mellitus.Review of the Quarterly Minimum Data Set (MDS) dated [DATE], documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 03 which indicated R82 had severe cognitive impairment, and Section I (Active Diagnosis) documented R82 had diabetes mellitus.Review of the care plan dated 03/02/2026, documented R82 has Diabetes Mellitus type 2. Goal: will have no complications related to diabetes through the review date. Intervention: Diabetes medication as ordered by doctor.Review of the Physician's orders dated 10/23/2024, documented metformin oral Tablet 500 milligrams (MG), give 2 tablets by mouth two times a day for Diabetes.Observation on 03/18/2026 at 9:06 AM during medication administration revealed Licensed Practical Nurse (LPN) FF used her bare hands to place a metformin tablet in the pill cutter to cut it in half to administer both halves to R82.2. Review of the facility's electronic medical records (EMR) documented R34 was admitted to the facility 06/02/2025 with diagnosis included but not limited to dysphasia.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) documented R34 was rarely or never understood, Section K (Swallowing/Nutritional Status) documented R34 had feeding tube.Review of the care plan dated 03/09/2026 documented R34 requires BOLUS PEG tube feeding with interventions to monitor/document/report as needed (PRN) any signs and symptoms (s/sx) of: Aspiration- fever, shortness of breath (SOB), tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormality.Review of the Physician's orders dated 10/23/2024 documented Cleanse G tube site with sterile saline, pat dry with dry, sterile dressing (DSD). Apply skin protectant to skin, then cover with split gauze and secure with tape.Observation on 03/19/2026 at 10:07 AM, revealed LPN EE did not sanitize her hands between glove change during R34's GT care.Interview on 03/18/2026 at 9:07 AM with LPN FF revealed she confirmed she used her bare hands to place a metformin 1000 mg tablet in the pill cutter to cut it in half to administer to R82. She stated R82 was ordered two 500 mg tablets but since the pharmacist sent 1000 mg tablets R82 preferred the tablet cut in half because it was a large tablet and she would take the two halves rather than one large tablet. LPN FF stated she should not have used her bare hands to hold the tablet because it caused cross contamination. and the R82 would get an infection.Interview on 03/18/2026 at 9:07 AM with the Director of Nursing (DON) revealed it is her expectations for the nurses not to handle medications with their bare hands. She stated that bare hands could contaminate the pills and if the residents get these medications, the residents could get whatever contamination was on the pills, possibly infection.Interview on 03/19/2026 at 10:15 AM with LPN EE confirmed and validated that she did not sanitize nor wash her hands between glove the change during GT care. She stated the hand sanitizer station in the room was empty and she did not have any hand sanitizer to use. She stated she should have washed her hands if there was no hand sanitizer. LPN EE further stated when she did not sanitize her hands nor wash her hands between glove change R34 could get an infection.Interview on 03/19/2026 at 2:01 PM with Nurse Manager (NM) CC confirmed that anytime gloves were removed, hands were to be washed or sanitized. She stated hands were to be washed or sanitized between glove changes and whenever this was not done, it was an infection control issue. The NM further stated that the residents could get infections such as Healthcare-Associated Infections (HAIs - infections patients contract while receiving treatment in healthcare settings, such as hospitals or nursing homes.)Interview on 03/19/2026 at 2:48 PM with the Director of Nursing (DON) revealed it is her expectation that staff sanitize their hands between glove changes. The DON stated that when the staff removed gloves they were to wash or sanitize their hands before putting on another pair of gloves because if they did not, it would cause spread of infection to the residents.

Based on observation, staff interviews and review of the facility's policies titled Storage of Medications, and Medication Administration, the facility failed to record an open date on one bottle of blood sugar strips in one medication cart and failed to lock one medication cart from the six medication carts reviewed for medication storage. This deficient practice had the potential to cause inaccurate blood sugar readings for the residents and unauthorized access of the medication cart with increased risk of diversion. Findings include:Review of the facility's policy titled Storage of Medications, revised [DATE] documented Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.Review of the facility's policy titled Medication Administration undated, documented PURPOSE: To provide a safe, effective medication administration process. PRACTICE STANDARDS: 1. Maintain security of cart and keys at all times.Observation on [DATE] at 10:18 AM revealed one medication cart outside of room [ROOM NUMBER] was unlocked and unattended. Observation further revealed no nurse was visible anywhere along the hall at that time.Observation on [DATE] at 5:40 PM during review of the Cedar cart medication cart revealed one bottle of glucometer strips was in the top drawer of the cart with no open date.Interview on [DATE] at 5:42 PM with Unit Manager (UM) CC, who was present during the review confirmed there was one bottle of blood sugar strips in the top drawer of the cart with no open date. She stated there should be an open date on the bottle because the strips lose their effectiveness after a certain time and no one would know when to discard the strips which if used might result in inaccurate blood sugar readings.Interview on [DATE] at 11:46 AM with Licensed Practical Nurse (LPN) EE, stated blood sugar strips should have open dates because there is a certain time frame they are good for use. She stated that if there was no open date no one would know when to throw out the strips and if used the strips might result incorrect blood sugar readings.Interview on [DATE] at 12:09 PM with the Director of Nursing (DON), stated it is her expectation for the medication carts to be locked when not in use. She stated medication carts must never be left open and unattended in the hallways of the facility. The DON stated blood sugar strips bottles must have open dates. She stated if the bottles do not have open dates, no one would know when the strips expired and may result in inaccurate blood sugar readings.

Based on record review, staff interviews and review of the facility's policies titled Minimum Data Set (MDS)/ Care Plans and Advance Directives, the facility failed to update the care plan for Advance Directives of Do Not Resuscitate (DNR) for one resident (R) (R94) of 54 residents reviewed for advance directives. This deficient practice had the potential to cause staff to initiate cardiopulmonary resuscitation (CPR) and all other necessary, life-sustaining treatments for cardiac and/or respiratory arrestFindings include:Review of the facility's policy titled Minimum Data Set (MDS)/ Care Plans reviewed [DATE] documented Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The Comprehensive Care Plan will be reviewed and revised on a quarterly basis. Procedure: 2. This comprehensive care plan will address resident goals, actual and potential problems, needs, strengths and individual preferences of the resident. 3. Each discipline will be responsible for the initiation and ongoing follow up for care plans as related to their area of expertise.Review of the facility's policy titled Advance Directives undated, documented Policy Statement: .Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation: Definitions: Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Page 9. If the Resident has an Advanced Directive: 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Facility staff are not required to provide care that conflicts with an advance directive.Review of the facility's electronic medical records (EMR) revealed that R94 was admitted to the facility on [DATE] with diagnosis included but not limited to malignant neoplasm of the tongue.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15 which indicated R94 had little to no cognitive impairment,Review of the care plan for R94, which was reviewed [DATE] documented included but not limited to Advance Directives, the resident signed a POLST upon admission into the facility and has selected to be a Do not resuscitate (DNR). The facility will honor the resident's wishes and perform CPR in the event of a medical emergency.Review of the Physician's orders dated [DATE] documented included but not limited to DNR.Interview on [DATE] at 11:38 AM with the MDS Director, stated that the MDS updated care plans and at times the nurses also updated the care plans. The MDS Director stated that the Social Services Director (SSD) was responsible for updating her sections of the care plan which included the Advance Directives. The MDS Director further stated the staff could administer CPR when they were not supposed to administer CPR to R94 and the staff would be going against R94's wishes since his Advance Directives stated that he was DNR.Interview on [DATE] at 11:52 AM with the SSD, confirmed and validated that the care plan goal for R94's Advance Directives stated, The facility will honor the residents wishes and perform CPR in the event of a medical emergency. She stated she was responsible for updating the Advance Directives care plan. The SSD stated that the care plan was to honor the resident's wishes and it was a personalized care plan. She stated the staff should look at the focus, but the goal and the interventions were the supporting details of the focus. The SSD further stated that it was human error and it was an oversight. She stated that when the care plan goal was to perform CPR and R94's Advance Directive was DNR there would be a conflict in care.Interview on [DATE] at 9:33 AM with Nurse Manager (NM) CC, stated the Advance Directives care plan was updated by the SSD. She stated care plans were individualized, and nurses followed the care plan for providing care.Interview on [DATE] at 2:50 PM with the Director of Nursing (DON), stated the Interdisciplinary Team (IDT) updated the care plan and each section was updated by the specific team member. She stated the SSD was responsible for updating the Advance Directives. The DON further stated that when the care plan goal stated to perform CPR and the focus stated DNR the nursing staff would try to find out if CPR was to be done for R94 or not and this could delay care.

Based on observations, record reviews, staff interviews, and review of the facility policy titled, Falls Management and Minimum Data Set (MDS)/Care Plans the facility failed to implement the care plan interventions to keep one resident (R) (R125) from a sample of 12 residents, free from avoidable falls. The deficient practice increased the risk of falls with injury.Findings include:Review of the facility policy undated and titled Falls Management, documented under Policy Standards .2. Develop individualized plan of care 3. Review and revise care plan regularly. Fall Prevention Ideas: Patients unable to transfer self: Mats at bedside. Fall out of W/C {wheelchair}: Keep wheelchair unlocked if resident has a need to move.Review of the facility policy titled, Minimum Data Set (MDS)/Care Plans dated 02/01/2024 documented under Procedure: . 2. The interdisciplinary team will develop and implement the Comprehensive Care Plan within 21 days of admission. The comprehensive care plan will address resident goals, actual and potential problems, needs, strengths and individual preferences of the resident.Review of the electronic medical record (EMR) revealed resident R125 was admitted to the facility on [DATE], with pertinent diagnoses including but was not limited to Medically Complex Conditions, Non-Alzheimer's Dementia, or Macular DegenerationReview of R125 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment. Section GG, functional status, revealed R125 required extensive assistance for activities of daily living (ADLs) with one/two or more-person assistance. R125 does benefit from the use of a wheelchair. Self-care: Partial/moderate assistance (eating, upper body dressing), Supervision or touching assistance (oral hygiene and personal hygiene), Substantial/maximal assistance (toileting, shower/bathe self, lower body dressing and putting on/taking off footwear). Mobility: Substantial/maximal assistance in most areas with the exception of Partial/moderate assistance sit to stand.Review of R125 care plan dated 01/01/2026 documented a problem area at risk for a fall related to impaired mobility, impaired cognitive functions and use of psychotropic medications. 03/10/2026 Fall no injury, 03/11/2026 Fall no injury, 03/16/2026 Fall no injury. Goals included but not limited to that R125 will not have falls with significant injury through review date. Interventions included but not limited to staff to assist resident to and from dining room and ensure wheelchair brakes are locked when wheelchair not in use.An interview on 03/19/2026 at 4:55 PM with LPN MDS Director stated MDS team does update care plans and add interventions based on information reported in the morning meetings. All changes are then conveyed to the team by the unit managers as MDS has no responsibility to ensure interventions are implemented.Observation on 03/19/2026 beginning at 11:31 AM, of staff that assisted R125 to the nurse's station area and locked his wheelchair. 11:44 AM revealed R125 trying to move his wheelchair in order to ambulate and he is unable to move the wheelchair with his feet. He is observed shuffling the locked wheelchair to the left. He stopped then looked down to see if he could unlock it and was not able as evidenced by him holding his hand out in confusion. At that point he stopped trying to move the wheelchair.Interview on 03/19/2026 at 12:52 PM with LPN GG revealed she does not lock resident's (R125) wheelchair because he should have free will. LPN GG stated she has seen him scoot in his wheelchair when the wheel is locked. She revealed if the resident/resident family asks for the wheelchair to be locked, they will lock it, if it is care planned, they will lock it.Interview on 03/19/2026 at 12:47 PM with CNA QQ revealed they constantly must check in on R125 because he is fast, very fast. She stated we unlock his wheelchair and try to leave it unlocked because he will attempt to ambulate in it with it locked. He will scoot, side by side in his wheelchair. Interview on 03/19/2026 at 1:06 PM with the Administrator revealed R125 knows how to unlock it [wheelchair] and other days he does not. She further revealed we do the best we can to manage his care.

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect and Misappropriation, the facility failed to ensure three of three residents (R) (R94, R89 and R37) were free from misappropriation of medication when narcotic medications were signed out and not administered. This deficient practice increased the risk of adverse clinical outcomes.Findings include:A review of the facility's policy titled Abuse, Neglect, and Exploitation reviewed 01/01/2025 documented Policy Statement: It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. The organization will include screening, training, prevention, identification, investigation, protection, and reporting to provide protection for the health, welfare, and rights of each resident residing in the facility.1. Review of the electronic medical record (EMR) revealed that R94 was admitted to the facility on [DATE] with diagnoses which included but not limited to left femur fracture and neoplasm of the tongue.Review of R94's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognition) R94 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated little to no cognitive impairment, Section P (Restraints and Alarms) R94 was on pain medication therapy related to chronic pain and end of life care.Review of R94's comprehensive Care Plan dated 02/10/2026 documented a Focus area for pain medication therapy related to (r/t) chronic pain and end of life care and intervention to administer pain medications as ordered by physician.A review of the Physician's Orders dated 02/12/2026 documented orders for Oxycodone 10 milligram (mg) 1 tablet as needed (PRN) every 4 hours for pain.A review of the facility's Investigation of Misappropriation of Narcotics report dated 10/07/2025 documented On 10/03/2025, Licensed Practical Nurse (LPN)/ Unit Manager (UM) GG signed out 2 {two} 5 mg {milligram} tablets and on 10/04/2025 she signed out 2 more 5 mg tablets. The resident stated he only received pain medications once from LPN/UM GG.2. Review of the EMR revealed R89 was admitted to the facility on [DATE] with diagnoses included but are not limited to malignant neoplasm of lower lobe left lung.Review of the Annual MDS assessment for R89 dated 01/28/2026 revealed Section C (Cognition) R89 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated little to no cognitive impairment, Section I (Active Diagnosis) R89 had metastatic cancer.Review of R89's comprehensive Care Plan dated 01/09/2026 revealed Focus area for risk of acute/chronic pain r/t Cancer (Lung) and history (hx) of right foot pain with intervention to administer analgesia as ordered and PRN.A review of the Physician's Orders for R89 revealed orders dated 09/05/2025 documented HYDROcodone-Acetaminophen Oral Tablet 5-325 MG, give 1 tablet by mouth every 6 hours as needed for pain do not exceed 3000mg/day. The order was discontinued on 09/25/2025.A review of the facility's Investigation of Misappropriation of Narcotics report dated 10/07/2025 documented On 10/03/2025, LPN/UM GG removed a 5mg/ 325mg oxycodone from the cart per her signature in the narcotic book. Per the electronic MAR {medication administration record,} it was not documented as given. R89 stated he did not ask for or receive pain medication and stated he doesn't even take it.3. A review of the EMR revealed R37 was admitted to the facility on [DATE] with diagnoses which included but are not limited to low back pain.A review of the Quarterly MDS assessment for R37 dated 02/16/2026 revealed Section C (Cognition) R37 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated little to no cognitive impairment, Section N (Medications) R37 received opiod medication.A review of R37's Care Plan dated 03/02/2026 revealed Focus area for pain medication therapy r/t low back pain and intervention to administer analgesic medications as ordered by physician.A review of the Physician's Orders for R37 revealed orders dated 10/15/2025 documented tramadol 50 mg tablet, give 1 tablet by mouth every 8 hour (s) as needed for pain.A review of the facility's Investigation of Misappropriation of Narcotics report dated 10/07/2025 documented On 10/4/2025, LPN/UM GG removed a tramadol from the narcotic box and signed the electronic MAR that it was given. R37 stated he didn't ask for pain medication, nor did he receive any from LPN/UM GG.Observation on 03/18/2026 of Med Pass revealed narcotic medications were administered to the residents and were administered as prescribed. The nurses stayed with the residents to ensure the narcotics were taken.Review of the facility's documents revealed the facility conducted audits continued monitoring and reviewed in Quality Assurance and Performance Improvement (QAPI.)Attempts were made to interview LPN/UM GG but were unsuccessful.Interview on 03/19/2026 at 4:45 PM with the Director of Nursing (DON) revealed she confirmed a full investigation for misappropriation of the resident's property was conducted on 10/4/2025 when she received a call from LPN/UM HH who stated that multiple PRN narcotics had been signed out during the prior night shift by LPN/UM GG for residents who did not usually request pain medication.Interview on 03/19/2026 at 5:10 PM with LPN/UM HH revealed she stated on 10/4/2025 she was a floor nurse, and she checked the narcotics when she came on duty for her 7:00 AM - 7:00PM shift. She stated LPN/UM GG usually worked the day shift, but she covered the night shift 7:00PM - 7:00 AM the prior shift. She stated LPN/UM GG already left when she came on duty and she checked the narcotics on her own. She stated that she was very familiar with the residents on the hall she usually worked, and she knew the residents who did not ask for or received pain medications, so she knew something was off when she saw narcotics signed out for residents who would not usually receive pain medications. She stated she went to the alert residents whose narcotics were signed out as given and asked R94, R89 and R37 if they received narcotic medications from LPN/UM GG and they said no. She stated she immediately reported it to the DON.

Based on resident and staff interviews, review of facility documentation, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure three residents (R) (R158, R140, and R59) of four residents reviewed were free from abuse. Specifically, R158 experienced physical abuse from a Certified Nursing Assistant (CNA) and R140 and R59 experienced emotional abuse by another resident. The deficient practice had the potential to affect resident psychosocial health and safety. Findings include:1. Review of the Facility Incident Report Form dated 11/21/2025 at 1:00 AM (Incident #202513043) revealed an allegation of staff-to-resident abuse in which R159 stated that he witnessed CNA AA kick R158 in the foot and leg while he was lying on the floor of the bathroom. Continued review of the initial report revealed that CNA AA was placed on suspension pending the outcome of the investigation and the staff were educated on the abuse policy and reporting requirements. Review of the Facility Incident Report (FRI) dated 11/21/2025 at approximately 2:00 AM, revealed that R159 alleged that a Certified Nursing Assistant (CNA) kicked R159 while he lay on the floor of his bathroom. Review of the undated Facility Incident Report (FRI) Follow Up revealed that R159 fell in the doorway of his shared bathroom where he laid for around 45 minutes before CNA AA arrived. He stated that CNA AA kicked R158 multiple times and spoke to him in a foreign language. R159 told CNA AA not to kick R158 but to get help. He stated she spoke to him in a foreign language and in a voice and tone which frightened him. He stated she left and returned with help, and they assisted R158 back to bed. Review of the electronic medical record (EMR) revealed that R158 was admitted to the facility with a diagnosis of dementia. He was assessed as being alert with confusion with a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognitive function. Continued review of the (FRI) Follow Up revealed that R159 (witness) was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hearing loss. The investigation included interviews with R159, interviews with residents on that unit, skin assessments and staff education presented on 11/21/2025, 11/24/2025, 12/03/2025, and 12/04/2025 related to staff-to-resident, resident-to resident abuse, and preventing abuse. In addition, nursing staff conducted interviews and performed skin assessments on the residents of the unit. The abuse allegation was substantiated, and CNA AA was terminated effective 11/21/2025. She could not be reached by phone during the course of the investigation or the standard/complaint survey. R158 and R159 were also discharged from the facility at the time of the standard/complaint survey.2. Review of the FRI dated 03/02/2026 at 2:20 PM revealed two incidents of resident-to-resident abuse in which R115 went into R59's room and stole her Vienna Sausage and Spam. In addition, R140 stated she walked into her bathroom and R115 was urinating and she saw his penis. He stated to her, next time I'll give you a better peak at it.R115 was immediately placed on one-to-one supervision, and a referral was placed for transfer to a behavioral unit. R115 was transferred to the local hospital for evaluation and treatment for his behavior and did not return to the facility. All staff received education on abuse, neglect, and exploitation. Review of the electronic medical record for R115 revealed he was admitted to the facility with diagnoses to include traumatic subdural hemorrhage, Wernicke's encephalopathy, dementia, compression of the brain, alcoholism, and malnutrition. Review of the admission Minimum Data Set (MDS) assessment for R115 dated 02/27/2026 revealed a Basic Interview for Mental Status (BIMS) score of 00 which indicated severe cognitive impairment (Section C), mood score of 02 which indicated little to no depression (Section D), and wandering behavior (Section E).Review of the care plan for R115 revealed focus concerns to include altered neurological status, knowledge deficit, risk for disturbed sensory, subdural hemorrhage with compression to brain, elopement risk/wanderer related to impaired safety/wandering and exit-seeking (02/22/2026), behavior problem of urinating in hallway/wandering into female bathrooms and urinating on the floor/taking food from another female room. Appropriate goals and interventions in place. Review of the Physician's Orders revealed an order to place R115 on 1:1 supervision, and transfer to a behavioral unit on 03/02/2026.Review of the EMR for R59 revealed she was admitted to the facility with diagnoses to include chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and depression. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating little to no cognitive impairment. In an interview with R59 on 03/18/2026 at 4:45 PM in the dining room, she stated she was sitting there in her bed when R115 came to the door and stood there for a moment then he kind of stormed into the room and grabbed her Spam and Vienna Sausage off her table and left the room. She stated it was kind of scary and she doesn't scare easily. She stated there have been no other incidents of that sort before or since then. She stated staff continued to check on her after the incident to make sure she was okay. In an interview with R140 on 03/18/2026 at 5:00 PM in her room, she stated she got up to go to the bathroom and when she opened the door, R115 was peeing into her toilet. She stated he entered from the other side of the adjoining bathroom. She stated she saw his penis, and he told her that he'd let her get a better peek next time. She stated she was shocked and scared and called for help. She stated staff came right away and he left with no problem. She stated no other incidents like that had occurred before or since and staff have been very attentive. Review of the facility policy titled, Abuse, Neglect, and Exploitation, reviewed/revised 04/15/2025, documented Policy statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Review of the Grievance Log dated 12/2025 through 1/2026 revealed no unresolved issues. Review of the Resident Council Minutes dated 12/2025 through 12/2025 revealed no unresolved issues. In an interview with CNA RR on 03/18/2026 at 2:30 PM, stated that she received education in abuse, neglect and exploitation and abuse reporting, at least monthly. She stated that they will also add more if something happens with a particular resident. She stated that she would report citing or allegation of abuse to the nurse and the Abuse Coordinator (AC) who is the Administrator. In an interview with CNA SS on 03/18/2026 at 2:40 PM, stated staff receive education in abuse and neglect all the time but at least monthly. She stated they also receive specific information for residents when they identify concerns. She stated she would report allegations to her charge nurse and the AC.In an interview with Licensed Practical Nurse (LPN) TT on 03/18/2026 at 2:50 PM, she stated that if she saw or heard of an abuse allegation, she would make sure her resident was safe, assess the resident, notify the physician or responsible party (RP), follow any new physician orders, and report to the Unit Manager (UM) and AC. She stated that staff receive abuse inservices sometimes several times a month.In an interview with LPN UU on 03/18/2026 at 3:00 PM, she stated that she would address abuse concerns by assessing the resident, notifying the physician, RP, UM, and AC. She stated that staff receive additional abuse inservice each time there is an abuse allegation. In an interview with LPN VV on 03/18/2026 at 3:10 PM, she stated that she would assess the resident who alleged abuse, notify the physician, RP, UM, and AC. She stated staff receive abuse education at least quarterly but usually more often. In an interview with LPN DD on 03/18/2026 at 3:20 PM, she stated that staff receive abuse education all the time, especially if there is an abuse allegation. She stated she would report an abuse allegation to her UM, Director of Nursing (DON), the physician or Nurse Practitioner (NP), RP, and the AC. In an interview with the Administrator on 03/18/2026 at 3:30 PM, she stated the staff receive frequent inservices on abuse, neglect, and exploitation, and she expected them to follow the protocols already in place to protect the residents

Based on observations, resident and staff interviews, record review and review of the facility's policy titled Medication: Self Administration and Bedside Medication Storage, the facility failed to remove one inhaler from the bedside of one resident (R) (R94) of 54 sampled residents. This deficient practice increased the risk of clinical complications. Findings include:Review of the facility's policy titled Medication: Self Administration reviewed December 2021 documented POLICY: Patients who request to self-administer medications will be assessed for capability. If it is determined that the patient is able to self-administer: A physician/mid-level provider order is required. Self-administration must be care planned. Patients must be provided with a secure, locked area to maintain medications. Patient must be instructed in self-administration. Periodic evaluation of capability must be performed. PURPOSE: To provide a safe, effective process for patient self-administration of medication.Review of the facility's policy titled Bedside Medication Storage undated, documented POLICY: Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing care center's interdisciplinary resident assessment team. PROCEDURES: The interdisciplinary team (IDT) will review and approve resident competencies and understanding prior to permission of bedside storage of medications as established in the nursing care centers policies and procedures. A written order for the bedside storage of medication is present in the resident's medical record. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.Review of the facility's electronic medical records (EMR) revealed R94 was admitted to the facility on [DATE] with diagnosis included but not limited to chronic obstructive pulmonary disease (COPD).Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 15 which indicated R94 had little to no cognitive impairment, and Section I (Active Diagnosis) documented R94 had COPD.Review of the care plan dated 02/10/2026, revealed there was no documented care plan for self-administration of medication for R94.Review of the Physician's orders revealed there was no documented order for self-administration of medication for R94.Review of the Physician's orders dated 09/10/2025, documented included but not limited to Stiolto Respimat Inhalation Aerosol Solution 2.5-2.5 MCG/ACT (micrograms per actuation - the exact dose of medication delivered with each spray or puff of an inhaler), (Tiotropium Bromide-Olodaterol HCl [hydrochloride]), Give 2 puffs by mouth every morning and at bedtime for COPD. Evaluate resident during inhalation therapy to ensure proper use of holding device, inhalation of medication and toleration of therapy. Use in conjunction with specific inhaler or nebulizer medication orders.Observation on 03/17/2026 at 11:54 AM revealed one Stiolto Respimat inhaler on R94's overbed table.Observation on 03/17/2026 at 3:25 PM revealed one Stiolto Respimat inhaler on R94's overbed table.Observation on 03/18/2026 at 9:05 AM revealed one Stiolto Respimat inhaler, one VapoCool sore throat spray and one CareAll chest rub on R94's bedside table.Observation on 03/18/2026 at 9:55 AM revealed one Stiolto Respimat inhaler, one VapoCool sore throat spray and one CareAll chest rub on R94's bedside table.Record review of R94's Assessments revealed no documented interdisciplinary team (IDT) Assessment for medication self-administration.Interview on 03/17/2026 at 11:55 AM with R94, stated the Stiolto Respimat inhaler which was on his overbed table was his and he had it at his bedside since the time he was admitted to the facility. R94 stated that he used the inhaler whenever he wanted to use it up to a few times each day. R94 further stated that the nurses knew the inhaler was at his bedside and they come in the mornings and evenings to give him an inhaler from the facility.Interview on 03/18/2026 at 9:56 AM with R94 in the presence of Licensed Practical Nurse (LPN) DD confirmed the medications were at his bedside since his admission and he took them whenever he desired. He stated he used the inhaler between the times when the nurses come and give him the facility's inhaler medication.Interview on 03/18/2026 at 10:00AM with LPN DD, confirmed and verified that one Stiolto Respimat inhaler, one VapoCool sore throat spray and one CareAll chest rub were on R94's bedside table. She stated that R94 should absolutely not have medications at the bedside and he should not be taking the medications on his own without the nurse knowing that he was taking them. LPN DD further stated that when R94 took the inhaler, the nurses had no control over the administration of that inhaler, and it would interfere with the other medications including another inhaler which he was receiving from the facility. She further stated R94 could take more than the amount he was supposed to take and it could exacerbate his medical condition. LPN DD stated R94 should not have medications at his bedside or take his own inhaler without staff knowledge.Interview on 03/18/2026 at 4:34 PM with LPN BB, stated medications must not be in residents' rooms and the residents should not take medications without the nurses knowing that they were taking their own medications. She stated that the residents who take their own medications could take too much of the medication.Interview on 03/18/2026 at 4:45 PM with the Director of Nursing (DON) confirmed it is her expectation that the residents should not have medications at the bedside. She stated residents needed to have doctor's orders, assessment from the IDT and care plan to self-administer medications. The DON confirmed R94 did not have a doctor's order, did not have an IDT Assessment and R94 was not care planned to self-administer medications. She stated R94 was admitted [DATE] and she was not aware if he had the inhaler at the bedside since admission. She further stated R94 could overmedicate and damage his lungs.

Based on observations, record reviews, staff interviews, and review of the facility policy titled Accidents/Incidents, and Falls Management, the facility failed to provide supervision for the prevention of falls for one resident (R) (R125) from a sample of five residents reviewed for falls and accidents. The deficient practice increased the risk of avoidable falls and injury.Findings include:A review of the facility policy undated and titled Accidents/Incidents, documented An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current standards of practice (e.g., drug side effects or reaction). An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security.A review of the facility policy undated and titled Falls Management, documented Policy: Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury.Review of the electronic medical record (EMR) revealed resident R125 was admitted to the facility on [DATE], with pertinent diagnoses including but was not limited to Medically Complex Conditions, Non-Alzheimer's Dementia, or Macular DegenerationReview of R125 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment. Section GG, functional status, revealed R125 required extensive assistance for activities of daily living (ADLs) with one/two or more-person assistance. R125 does benefit from the use of a wheelchair. Self-care: Partial/moderate assistance (eating, upper body dressing), Supervision or touching assistance (oral hygiene and personal hygiene), Substantial/maximal assistance (toileting, shower/bathe self, lower body dressing and putting on/taking off footwear). Mobility: Substantial/maximal assistance in most areas with the exception of Partial/moderate assistance sit to stand.Review of R125 care plan dated 01/01/2026 documented a problem area at risk for a fall related to impaired mobility, impaired cognitive functions and use of psychotropic medications. 03/10/2026 Fall no injury, 03/11/2026 Fall no injury, 03/16/2026 Fall no injury. Goals included but not limited to that R125 will not have falls with significant injury through review date. Interventions included but not limited to staff to assist the resident to and from the dining room and ensure wheelchair brakes are locked when the wheelchair not in use.Review of R125 care plan dated 01/01/2026 and revised 03/16/2026 indicated a problem of R125 is an elopement risk/wanderer related to demented and wanders aimlessly. Goals included but not limited to R125 will not leave facility unattended through the review date. Interventions included but not limited to Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, Wander alert bracelet on right wrist.Observation on 03/19/2026 beginning at 11:31 AM, of staff that assisted R125 to the nurse's station area and locked his wheelchair. 11:44 AM revealed R125 trying to move his wheelchair in order to ambulate and he is unable to move the wheelchair with his feet. He is observed shuffling the locked wheelchair to the left. He stopped then looked down to see if he could unlock it and was not able as evidenced by him holding his hand out in confusion. At that point he stopped trying to move the wheelchair.Interview on 03/19/2026 at 12:52 PM with LPN GG revealed she does not lock resident's (R125) wheelchair because he should have free will. LPN GG stated she has seen him scoot in his wheelchair when the wheel is locked. She revealed if the resident/resident family asks for the wheelchair to be locked, they will lock it, if it is care planned, they will lock it.Interview on 03/19/2026 at 12:47 PM with CNA QQ revealed they constantly must check in on R125 because he is fast, very fast. She stated we unlock his wheelchair and try to leave it unlocked because he will attempt to ambulate in it with it locked. He will scoot, side by side in his wheelchair. Interview on 03/19/2026 at 1:06 PM with the Administrator revealed R125 knows how to unlock it [wheelchair] and other days he does not. She further revealed we do the best we can to manage his care.

Based on staff interviews, record review, and review of the facility's policy titled Patient/Resident Trust Funds, the facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for six of six months reviewed. This deficient practice had the potential to adversely affect the finances of 84 residents with trust fund accounts managed by the facility. Findings include: Review of the facility's undated policy titled Patient/Resident Trust Funds, dated 2/1/2024, revealed the Policy section included, It is the policy of this healthcare center to maintain all resident trust fund money, except for petty cash, in one interest-bearing checking account. Review of the facility's Surety Bond revealed the penal sum of $85,207.06. The bond stated, The liability of the surety for any and all losses incurred under this bond shall not exceed the stated penal sum. Review of a facility-provided invoice revealed the Resident Personal Fund Bond was effective from 4/21/2024 to 4/21/2025, and the bond amount was $85,207.06. Review of the facility's Resident Fund Trust Account bank statements revealed the ending balance for August 2024 was $107,015.20, for September 2024 was $115,620.23, for October 2024 was $121,247.26, for November 2024 was $120,513.10, for December 2024 was $142,282.45, and for January 2025 was $144,539.69. Review of the facility-provided document titled Resident Fund Management Service revealed that 84 residents had an active resident trust fund account at the facility. In a post-survey telephone interview on 2/21/2025 at 11:30 am, the Administrator confirmed the facility's Surety Bond was for the amount of $85,207.06. She further verified that the resident trust fund end-of-the-month bank statement totals for the months of August 2024 through January 2025 were in excess of the amount of the Surety Bond. She stated she was unaware that the Surety Bond amount was less than the resident trust fund monthly balances and that the Surety Bond amount should be more than the resident trust fund balances to ensure the security of the resident's personal funds. She further stated that the corporate office had requested an increase in the Surety Bond coverage.

Based on observations, staff interviews, record review, and review of the facility's policy titled Storage of Medication, the facility failed to ensure there were no expired medications in two of two medication storage rooms. The deficient practice had the potential to place residents at risk of receiving expired medications. Findings include: Review of the facility's policy titled Storage of Medication, dated 1/2025, revealed the Procedures section included . 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. On 2/16/2025 at 10:45 am, observation of the Gardenia Hall medication storage room with Licensed Practical Nurse (LPN) BB revealed the following: Three containers of mineral oil lubricant laxative with an expiration date of 11/19/2024. Three containers of iron supplement liquid with an expiration date of 9/2024. Two containers of arthritis relief with an expiration date of 10/2024. LPN BB confirmed the medications were expired and discarded the expired drugs. On 2/16/2025 at 12:30 pm, observation of the Sunnyville Hall medication storage room with Registered Nurse (RN) CC revealed three containers of Geri Lanta with an expiration date of 1/2025. RN CC confirmed the expired medication and discarded it. She stated she was unsure why the expired medication was in the medication storage room and that the nurses randomly checked the medication expiration dates. In an interview on 2/17/2025 at 11:22 am, the Director of Nursing (DON) stated that the nurses were instructed to look at the expiration date when medications were taken from the medication storage rooms.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure that one of 51 sampled residents (R) (R55) was assessed for safe medication self-administration before allowing medications to be stored at the bedside. This deficient practice had the potential to place R55 at risk of self-administering medications in an unsafe manner. Findings include: Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, reviewed 1/1/2025, revealed the Policy statement included, Each resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse/Registered Nurse and physician have determined that the practice would be safe for the resident and other residents of the healthcare center. The section titled Procedure included . 2. If the resident or family member desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. 6. All nurses and aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Review of R55's electronic medical record (EMR) revealed diagnoses including, but not limited to, chronic atrial fibrillation, muscle weakness, chronic combined systolic and diastolic heart failure, essential hypertension, unilateral primary osteoarthritis of the right knee, anxiety disorder, major depressive disorder, and other chronic pain. Review of R55's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of R55's care plan revealed no care area or interventions for medication self-administration. Review of R55's Physician Orders revealed no orders for medication self-administration. Review of R55's EMR revealed no documentation of evaluation for self-administration of medications. Observation on 2/15/2025 at 8:49 am in R55's room revealed one container of diclofenac sodium one percent cream (a topical medication used to treat pain) on the resident's bedside table. The resident stated that the cream was provided by her sister and used for knee pain relief. She acknowledged that she used the cream as needed. Observation on 2/16/2025 at 9:43 am in R55's room revealed that the diclofenac sodium one percent cream remained on the bedside table. Further observation revealed a container of sore throat spray. The resident stated that a nurse had allowed her to keep the sore throat spray at her bedside because it could not be placed on the medication cart. During a simultaneous observation and interview on 2/16/2025 at 9:05 am, Certified Nursing Assistant (CNA) DD revealed that she was unaware of the medication in R55's room. She stated that she was unsure if R55 was allowed to have the items at the bedside. During simultaneous observation and interview on 2/16/2025 at 9:14 am, Unit Manager (UM)/Licensed Practical Nurse (LPN) EE revealed that facility staff were unaware of the medications in R55's room. He acknowledged that family members frequently bring unauthorized items, and staff must monitor and remove them. During an interview on 2/16/2025 at 3:37 pm, the Director of Nursing (DON) confirmed that the facility does not allow self-administration of medications without a physician's order and assessment by the interdisciplinary team. The DON stated that if a resident had medication in their possession, it was typically brought in by a family member without the facility's knowledge. She acknowledged that unauthorized medications should be removed and that education should be provided to the resident and family.

Based on staff interviews and record review, the facility failed to ensure that one of five residents (R) (R475) with an indwelling urinary catheter had a qualifying medical diagnosis for the use of an indwelling urinary catheter. The deficient practice had the potential to place R475 at risk of avoidable urinary tract complications. Findings include: Review of R475's electronic medical record (EMR) revealed diagnoses including, but not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder, generalized anxiety disorder, and a personal history of urinary tract infections. Review of R475's Admission Minimum Data Set (MDS), dated [DATE], revealed section H (Bowel and Bladder) documented the resident had an indwelling catheter. Section I (Active Diagnoses) did not include any genitourinary diagnoses. Section M (Skin Condition) documented that there were no wounds. Review of R475's Physician's Orders revealed an order dated 2/14/2025 for a urinary catheter 16 French with a 10 cc (cubic centimeter) balloon to bedside drainage for diagnosis/history of wounds. In an interview on 2/4/2025 at 9:30 am, the Director of Nursing (DON) confirmed that R475 did not have a clinically qualifying diagnosis for the use of an indwelling urinary catheter. The DON stated that the provider would be notified.

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Misappropriations, the facility failed to ensure pre-employment screenings, specifically a background check for one employee and a background check and fingerprints for one employee, were obtained for two of 10 staff reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The facility census was 126 residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Misappropriations, effective date 2/1/2024, revealed the Policy Components section included A. Screening . 3. Criminal background checks will be conducted prior to permanent employment. Review of the facility employee files revealed the following: 1. The Director of Nursing (DON) was hired on 2/22/2023 with no background process completed. 2. The Dietary Manager (DM) was hired on 2/7/2023 with no background or fingerprint process completed. A review of the facility-provided Employee Roster Georgia Criminal History Check System (GCHEXS) report revealed that the DON or DM were not listed on the report. The DON had an active, unencumbered Registered Nurse (RN) license. There were no concerns identified related to abuse or neglect within the facility during the survey. In an interview on 2/16/2024 at 1:15 pm, the Human Resources (HR)/Payroll Manager stated the corporate office was aware that the DON was missing a background check and the DM was missing a background check and fingerprints. In an interview on 2/16/2024 at 3:35 pm, the Administrator stated that there was an issue with their system in retrieving the fingerprints and background checks for the identified employees. In a post-survey interview on 2/24/2025 at 11:45 am, the Administrator stated she was unable to locate a background check for the DON or a background check and fingerprints for the DM. She stated the facility's HR Manager had recently left employment, and she was unable to locate the reports. She confirmed both employees' hire dates and stated she felt sure both had the required checks performed after the facility's last recertification survey. She stated she did not know why the DM was not included in the GCHEXS report and confirmed she should be on the report if she had had her fingerprints performed.

Based on staff interviews, record review, and review of the facility's policy titled Care Planning-Interdisciplinary Team, the facility failed to ensure that one of five residents (R) (R475) with an indwelling urinary catheter had a person-centered comprehensive care plan for the use of the indwelling urinary catheter. This deficient practice had the potential to place R475 at risk of not receiving treatment and/or care according to their needs. Findings include: Review of the facility's undated policy titled Care Planning-Interdisciplinary Team revealed the Policy Interpretation and Implementation section included, 1. A comprehensive care plan for each resident is developed after completion of the resident assessment (MDS) [Minimum Data Set]. Review of R475's electronic medical record (EMR) revealed diagnoses including, but not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder, generalized anxiety disorder, and a personal history of urinary tract infections. Review of R475's Admission Minimum Data Set (MDS), dated [DATE], revealed section H (Bowel and Bladder) documented the resident had an indwelling catheter. Review of R475's care plan dated 2/14/2025 revealed no care area or interventions for the indwelling urinary catheter. In an interview on 2/4/2025 at 9:15 am, the MDS Coordinator verified there were no care areas or interventions for an indwelling urinary catheter on R475's care plan. The MDS Coordinator stated that the care plan should include a care area and interventions for the indwelling urinary catheter. She stated that the oversight occurred because the resident was initially admitted for respite care, and the catheter was not considered a priority at that time.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled Hand Hygiene and Infection Prevention and Control Policy, the facility failed to ensure infection control processes were followed during resident care for three residents (R). Specifically, during a fingerstick blood sugar (FSBS) test for one of 36 R requiring a FSBS (R8), during wound care for one of 20 R receiving wound care (R6), and for one of eight R receiving tube feeding (R91). The deficient practices had the potential to place R8, R6, and R91 at risk of avoidable exposure to infections. Findings include: Review of the facility's policy titled Hand Hygiene, effective date 2/1/2024, revealed the Policy Statement included, . Handwashing is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident contact in an effort to prevent the spread of infection. Hands must be washed after the following, including, but not limited to: contact with blood/body fluids, contact with contaminated items or surfaces, initiating a clean procedure, and removal of gloves. Review of the facility policy titled ''Infection Prevention and Control,'' effective date 2/1/2024, revealed the Policy Statement included, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. Review of R8's electronic medical record (EMR) revealed diagnoses including, but not limited to, type 1 diabetes mellitus. Review of R8's Physician Orders revealed an order dated 11/12/2024 for a FSBS two times a day. Observation on 2/16/2025 at 9:38 am of Licensed Practical Nurse (LPN) AA performing a FSBS on R8 revealed that LPN AA put on gloves, performed the FSBS, removed the gloves, put on a pair of gloves, and sanitized the glucometer (a machine used to check blood sugar). LPN AA did not sanitize her hands between glove changes. In an interview on 2/17/2025 at 11:44 am, the Infection Control Nurse (ICN) stated that staff should wash their hands before and after dealing with patients and that nurses should sanitize their hands between glove changes. In an interview on 2/17/2025 at 4:10 pm, the Director of Nurses (DON) stated she expected staff to follow procedures and guidelines for infection control. 2. Observation on 2/17/2025 at 9:10 am of the Wound Care Nurse (WCN) performing wound care for R6 revealed that she carried a tray of wound care supplies into R6's room and placed the tray on the resident's bedside table without sanitizing the table or placing a barrier on it. After wound care was complete, the WCN placed the tray on the treatment cart without cleaning the tray or placing a barrier on the cart. The WCN stated she forgot to sanitize the bedside table, the tray, and the treatment cart. In an interview on 2/17/2025 at 11:30 am, the ICN stated there should have been a barrier used on the bedside table and the treatment cart. In an interview on 2/17/2025 at 4:10 pm, the Director of Nurses (DON) stated she expected staff to follow procedures and guidelines for infection control. 49396 3. Review of R91's Quarterly Minimum Data Set (MDS), dated [DATE], revealed section K (Swallowing/Nutritional Status) documented that R91 had a feeding tube and received 51 percent or more of total calories through the tube feeding. An observation on 2/15/2025 at 8:57 am in R91's room revealed a catheter tip syringe lying on the bedside table, unbagged and unlabeled. In a concurrent observation and interview on 2/15/2025 at 8:17 am, LPN GG verified the unbagged syringe on R91's bedside table and stated that all enteral feeding syringes should be labeled, stored properly, and disposed of if not in use. In an interview on 2/16/2025 at 3:17 pm, the DON revealed that all enteral feeding syringes should be bagged and labeled with the resident's name and date and that staff was responsible for ensuring all enteral feeding equipment was properly stored and discarded after use.

Based on observations, staff interviews, record reviews, and a review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. There were three errors with 29 opportunities for two of four residents (R) (R43 and R74) observed during medication administration. The medication error rate was 10.34 percent. These failures had the potential to place R43 and R74 at risk of medical complications and decreased therapeutic effects of medications. Findings include: Review of the facility's undated policy titled Medication Administration revealed the Policy section included A licensed nurse, Med Tech (medication technician), or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed. The Purpose section stated, To provide a safe, effective medication administration process. 1. Review of R43's Physician's Orders revealed an order dated 8/13/2024 for divalproex sodium oral capsule delayed release (DR) sprinkle 125 milligrams (mg), four capsules by mouth one time a day related to unspecified convulsions. Observation on 2/16/2025 at 9:01 am revealed that Licensed Practical Nurse (LPN) AA administered divalproex sodium oral capsule DR sprinkle 125 mg one capsule by mouth to R43. 2. Review of R74's Physician's Orders revealed an order dated 2/6/2024 for vitamin B12 oral tablet extended release (ER) 1000 micrograms (mcg), one tablet by mouth one time a day. Further review revealed an order dated 9/26/2023 for calcium carbonate 600 mg oral tablet, one tablet by mouth daily. Observation on 2/16/2025 at 9:20 am revealed that LPN AA administered vitamin B12 1,000 mcg regular release one tablet by mouth and calcium carbonate 500 mg oral tablet one tablet by mouth to R74. In an interview on 2/16/2025 at 12:15 pm, LPN AA confirmed she administered R43 divalproex sodium oral capsule DR sprinkle 125 mg one capsule by mouth and confirmed the physician's order was for divalproex sodium oral capsule DR sprinkle 125 mg four capsules by mouth. She confirmed she administered R74 vitamin B12 1,000 mcg regular release, one tablet by mouth, and the physician's order was for vitamin B12 oral tablet ER 1000 mcg, one tablet by mouth, and further confirmed she administered R74 calcium carbonate 500 mg oral tablet one tablet by mouth and the physician's order was for calcium carbonate 600 mg oral tablet one tablet by mouth. In an interview on 2/17/2025 at 11:05 am, the Director of Nursing (DON) stated that LPN AA was a new nurse and needed additional training. The DON further stated that when administering medications, the nurse should look at the order on the Medication Administration Record (MAR) and follow the physician's orders.

Based on observations, staff interviews, record review, and review of the facility's policies titled Catheter Care, and Quality of Life-Dignity, the facility failed to promote, maintain, and protect residents' dignity for one of five residents (R) (R475) with an indwelling urinary catheter. This failure had the potential to diminish R475's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the facility's policy titled Catheter Care, dated 7/1/2024, revealed the Policy section stated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The Policy Explanation section included, . 2. Privacy bags will be available and catheter drainage bags will be covered at all times when in use. Review of the facility's undated policy titled Quality of Life-Dignity revealed the Policy Statement stated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The Policy Interpretation and Implementation section included, . 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered. Review of R475's electronic medical record (EMR) revealed diagnoses including, but not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder, generalized anxiety disorder, and a personal history of urinary tract infections. Review of R475's Admission Minimum Data Set (MDS), dated [DATE], revealed section GG (Functional Abilities and Goals) documented the resident was dependent for activities of daily living (ADLs). Section H (Bowel and Bladder) documented that the resident had an indwelling catheter. Observations on 2/15/2025 at 9:32 am and 9:58 am revealed R475 in her room with the door open. The urinary catheter drainage bag was secured to the bed frame, not in a privacy bag, allowing her urine to be visible from the hallway. During an interview on 2/15/2025 at 9:32 am, R475 expressed concerns about the lack of privacy. During a simultaneous observation and interview on 2/15/2025 at 9:59 am, Licensed Practical Nurse (LPN) GG acknowledged that R475's catheter should have been covered. During an interview on 2/16/2025 at 9:05 am, Certified Nursing Assistant (CNA) FF stated she had replaced R475's urinary catheter drainage bag on 2/15/2025 morning and ensured it was placed in a privacy bag. She verified that the catheter drainage bag had been uncovered and exposed prior to her replacing the bag. During an interview on 2/16/2024 at 1:00 pm, the Director of Nursing (DON) stated that R475 had transferred from a personal care home a couple of days ago. She stated that the staff had forgotten to cover the catheter bag after R475 returned to the facility. She stated that he expected staff to ensure the resident's urinary catheter drainage bag was covered at all times.

Based on record review, staff interviews, and review of the facility policy titled, Transfer and Discharge Including AMA [against medical advice], the facility failed to ensure the Ombudsman was notified for six of six residents (R) (R5, R1, R2, R7, R8, and R11) reviewed for discharge from the facility. Findings include: Review of the facility's undated policy titled, Transfer and Discharge Including AMA, revealed the Policy was It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. The Policy Explanation and Compliance Guidelines section included . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: . h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. 12. h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. 1. Review of R5's Admission Record revealed she was admitted to the facility on [DATE], transferred to the hospital on 11/15/2023, did not return to the facility, and was discharged from the facility on 11/22/2023. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section Q (Resident Participation in Assessment and Goal Setting) documented active discharge planning was not occurring for the resident to return to the community. Review of the care plan dated 11/16/2023 revealed no documentation of a care plan for discharge planning. Review of a Social Service Note dated 11/24/2023 revealed, SSD [Social Service Director] called the resident's legal guardian and notified that the resident was off of bed hold and we would not be able to take her back. Review of R5's electronic medical record (EMR) revealed no documentation that the Ombudsman was notified that R5 was discharged from the facility. 2. Review of R1's Admission Record revealed she was admitted to the facility on [DATE], transferred to the hospital on 1/19/2024, did not return to the facility, and was discharged from the facility on 1/19/2024. Review of the Annual MDS assessment dated [DATE] revealed Section Q (Resident Participation in Assessment and Goal Setting) documented active discharge planning was not occurring for the resident to return to the community. Review of the care plan dated 1/7/2024 revealed no documentation of a care plan for discharge planning. Review of a Social Service Note dated 1/19/2024 revealed, The resident's daughter called the facility on 1/18/2024 and stated she was discharging her mother from the facility . Review of R1's EMR no documentation that the Ombudsman was notified that R1 was discharged from the facility. 3. Review of R2's Admission Record revealed he was readmitted to the facility on [DATE] and was discharged from the facility on 3/14/2024. Review of the Annual MDS assessment dated [DATE] revealed Section Q (Resident Participation in Assessment and Goal Setting) documented active discharge planning was not occurring for the resident to return to the community. Review of the care plan revealed no documentation of a care plan for discharge planning. Review of the Progress Notes eINTERACT Change in Condition Evaluation V5 dated 3/12/2024 documented that R2 was assessed by the Nurse Practitioner and was transferred to the hospital. Review of R2's EMR revealed no documentation that the Ombudsman was notified that R2 was discharged from the facility. 4. Review of R7's Admission Record revealed he was admitted to the facility on [DATE], transferred to the hospital on 9/3/2024, did not return to the facility, and was discharged from the facility on 9/10/2024. Review of the Quarterly MDS assessment dated [DATE] revealed Section Q (Resident Participation in Assessment and Goal Setting) documented active discharge planning was not occurring for the resident to return to the community. Review of the care plan dated 4/12/2023 revealed no documentation of a care plan for discharge planning. Review of the Progress Notes eINTERACT Change in Condition Evaluation V5 dated 9/3/2024 documented that R7 was sent to the emergency room . There was no documentation that the Ombudsman was notified that R7 was discharged from the facility. 5. Review of R8's Admission Record revealed he was readmitted to the facility on [DATE] and was discharged from the facility on 10/19/2023. Review of the Discharge MDS assessment dated [DATE] revealed Section Q (Resident Participation in Assessment and Goal Setting) documented active discharge planning was not occurring for the resident to return to the community. Review of the care plan dated 4/12/2023 revealed no documentation of a care plan for discharge planning. Review of the Progress Note (general) dated 10/19/2023 revealed R8 left the facility with emergency medical service to be admitted to hospice care. There was no documentation that the Ombudsman was notified that R8 was discharged from the facility to hospice care. 6. Review of R11's Admission Record for R11 revealed he was admitted to the facility on [DATE], transferred to the hospital on 12/21/2023, did not return to the facility, and was discharged from the facility on 12/23/2023. Review of the Admission MDS assessment dated [DATE] revealed Section Q (Resident Participation in Assessment and Goal Setting) documented active discharge planning was not occurring for the resident to return to the community. Review of the care plan dated 12/22/2023 revealed no documentation of a care plan for discharge planning or desires. Review of the Progress Notes eINTERACT Change in Condition Evaluation V5 dated 12/23/2023 revealed R11 was transferred to the hospital. There was no documentation that the Ombudsman was notified that R11 was discharged from the facility. In an interview on 11/12/2024 at 10:57 am, the SSD stated she was unaware the Ombudsman should be notified when a resident is discharged from the facility. She stated the Ombudsman visited the facility frequently and had never communicated she wanted to be notified of discharges. In an interview on 11/12/2024 at 3:45 pm, the Administrator stated she spoke with the SSD and was made aware that the Ombudsman had not been notified of resident discharges from the facility. The Administrator stated she has also spoken with the Ombudsman regarding the preference of communication of the resident discharges. The Administrator stated a process would be implemented to ensure that the Ombudsman was aware of the discharged residents going forward.

Based on observations, staff interviews, and review of the facility's policies titled, Glucometer Disinfection, and Infection Prevention and Control, the facility failed to ensure the infection control process was followed by two of three nurses observed using a glucometer (a device used to measure blood glucose) to check resident's blood sugar levels. The deficient practices had the potential to increase the potential for cross-contamination and spread of infection. Findings include: Review of the facility's policy titled, Glucometer Disinfection, dated 11/2017, revealed the Policy stated, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. The Policy Explanation and Compliance Guidelines section included 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 3. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review of the facility's policy titled, Infection Prevention and Control, dated 2/1/2024, revealed the Policy Statement was An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The Policy Interpretation and Implementation section included . 11. Prevention of Infection a. Important facets of infection prevention include: . (3) educating staff and ensuring that they adhere to proper techniques and procedures. An observation on 11/8/2024 at 10:57 am of Licensed Practical Nurse (LPN) EE performing a glucometer test on R25 revealed the LPN removed the glucometer from the medication cart and placed the glucometer on top of the medication cart without a barrier. The LPN gathered additional supplies, carried the supplies to the resident's room, and placed the glucometer and supplies on the overbed table without placing a barrier on the table or sanitizing the table. After obtaining the resident's blood sugar, the LPN exited the room and placed the glucometer in the medication cart on top of the pill crushers. The LPN stated that before placing the glucometer in the medication cart, it should have been cleaned with a sanitizing wipe. An observation on 11/8/2024 at 11:57 am of LPN DD performing a glucometer test on R9 revealed the LPN removed the glucometer and supplies from the medication cart and placed the items on top of the medication cart without a barrier. After entering R9's room, the LPN placed the glucometer and supplies on the overbed table without a barrier or sanitizing the table. The LPN stated a barrier should have been used before placing the items on any surface. In an interview on 11/8/2024 at 12:10 pm, the Director of Nursing (DON) stated the glucometer machines should be cleaned with a germicidal disposable wipe after each use. She further stated a barrier must be used when placing the glucometer and supplies on any surface. The DON stated she would start educating the staff on the proper way to disinfect the glucometer and use a barrier.

Based on resident interviews, staff interviews, review of the facility policy titled, Patient/Resident Trust Funds, and review of the facility-provided document titled, Resident Fund Accounts, the facility failed to provide resident trust fund account quarterly statements for three of 100 residents (R) with trust fund accounts managed by the facility (R4, R6, and R9). This deficient practice had the potential to affect all residents who had a trust fund account with the facility. Findings include: Review of the facility policy titled, Patient/Resident Trust Funds, dated 2/1/2024, revealed the Procedure section included .3. At the time of admission, the resident will sign an authorization indicating understanding of the policy and giving the healthcare center authorization to handle such funds. This authorization is to be maintained in the financial file. Review of the undated document located in the resident admission packet titled, Resident Fund Accounts revealed, The center shall furnish resident/patients with quarterly statements at the end of each calendar quarter. 1. Review of R6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 15 (indicating intact cognition). Review of the document titled Resident Fund Accounts revealed it was signed by R6's resident representative and the facility representative on 11/4/2018. Review of the Trial Balance dated 10/31/2024 and Resident Fund Statement revealed R6 had a resident trust fund account managed by the facility. In an interview on 11/7/2024 at 10:25 am, R6 stated she had a trust fund account that the facility managed. The resident stated the last quarterly statement the facility provided to her was in February 2024. The resident stated she would like to receive statements and to know how much money is in the account. In an interview and observation on 11/12/2024 at 1:15 pm with the Business Office Manager (BOM) and R6, R6 stated she had not received a statement since February 2024. The resident gave the BOM permission to look through the nightstand for a statement. The BOM did not locate a quarterly statement. 2. Review of R4's Annual MDS assessment dated [DATE] revealed a BIMS was assessed as 15 (indicating intact cognition). Review of the Trial Balance dated 10/31/2024 and Resident Fund Statement revealed R4 had a resident trust fund account managed by the facility. In an interview on 11/8/2024 at 11:25 am, R4 stated she had a trust fund account that the facility managed. The resident stated she did not receive a quarterly statement for the trust fund account. The resident stated someone in the front office would tell her the balance in the account if she (R4) asked. 3. Review of R9 MDS Quarterly assessment dated [DATE] revealed a BIMS was assessed as 15 (indicating intact cognition). Review of the Trial Balance dated 10/31/2024 and Resident Fund Statement revealed R9 had a resident trust fund account managed by the facility. In an interview on 11/12/2024 at 10:50 am, R9 stated he had a trust fund account that the facility manages and did not receive the quarterly statements. R9 stated he did not know how much money was in his account. In an interview and observation on 11/12/2024 at 1:25 pm with the BOM and R9, R9 stated he did not receive bank statements. The resident gave the BOM permission to look through his dresser drawers for a quarterly statement. The BOM did not locate a quarterly statement. In an interview on 11/12/2024 at 11:51 am, the BOM stated she managed the residents' trust fund accounts. She stated the statements were provided to the residents quarterly. The BOM stated the resident quarterly statements were placed in an envelope by the business office and provided to the Receptionist and Activities Director for distributing to the residents. The BOM stated it was ultimately the responsibility of her office to ensure the residents received the quarterly bank statement.

Based on interviews, record review and review of facility's policies, the facility failed to ensure [CONDITION(S)] ([CONDITION(S)]) care management for an artificial airway (cuff inflation, airway cleaning, tube changes, assessments and ongoing monitoring of respiratory functioning) was provided by competent, trained and skilled licensed staff, who were allowed to provide [CONDITION(S)] care for four of five sampled residents (Resident (R) 5, R24 R37 and R31). On 2/8/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency [CONDITION(S)] supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing [CONDITION(S)] supplies at the bedside in the resident's room and extra [CONDITION(S)] supplies in the nursing supply room, in-servicing nursing staff on location of [CONDITION(S)] supplies and [CONDITION(S)] care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of [CONDITION(S)] supplies, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 2/10/2022. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of facility-provided paper document titled, Facility Assessment Tool, dated 04/22/21 under the heading Staff training, education and competencies ., revealed .Training and competencies are maintained in the associates personnel file and updated periodically & annually as determined by center and recertification needs. Review of facility-provided paper document titled, Assistant Director or Nursing [ADON] job description revealed .Ensures that staff participates in training programs .relevant policies and procedures Review of facility-provided paper document titled, Licensed Practical Nurse [LPN] job description revealed .Attends continuing education programs to maintain competency . Requested from the facility a policy for [CONDITION(S)] management and [CONDITION(S)] emergency management. The facility did not provide policy for review. Review of the facility-provided policy titled, [CONDITION(S)] Care-Suctioning dated 09/19/20 date revealed, .The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. 1. Review of R5's undated Face Sheet provided by the facility revealed R5 was admitted to the facility on [DATE]. R5 was admitted with a [CONDITION(S)]. Review of R5's Physician Orders, located in the resident's electronic medical record (EMR) under the Orders tab revealed an order dated 10/19/21 of Shiley (brand of [CONDITION(S)]) #6. Observations on 02/07/22 at 11:44 AM and 12:15 PM revealed no emergency supplies visible at bedside or in R5's room. An interview was conducted on 02/07/22 at 4:14 PM with Licensed Practical Nurse (LPN) 2 regarding R5. LPN2 stated she did not know how to use an emergency [CONDITION(S)] kit. LPN2 further stated she had not received [CONDITION(S)] care or emergency [CONDITION(S)] training at this facility. 2. Review of 23's undated Face Sheet provided by the facility revealed R23 was admitted to the facility on [DATE]. R23 was admitted with a [CONDITION(S)]. Review of R23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 02/07/22 at 2:15 PM and 2:42 PM revealed an ambu (self-inflating bag resuscitator) bag hanging on R23's closet door and a red cloth bag hanging on the closet door. The emergency kit (red cloth bag) was missing sterile gloves, lubricating jelly, and obturator. An interview was conducted on 02/07/22 at 4:46 PM with LPN3 regarding R23. LPN3 stated she did not know the location of [CONDITION(S)] emergency supplies for R23. 3. Review of R27's undated Face Sheet provided by the facility revealed R27 was admitted to the facility on [DATE]. R27 was admitted with a [CONDITION(S)]. Review of R27's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 02/07/22 at 2:12 PM and 3:22 PM, and 4:44 PM (with LPN3) revealed no emergency supplies available in R27's room. An interview was conducted on 02/07/22 at 4:44 PM with LPN3 regarding R27. LPN3 stated she did not know what emergency equipment would be used if R27's [CONDITION(S)] became dislodged. LPN3 further stated she received approximately two minutes of training regarding suctioning of [CONDITION(S)] but did not receive training on emergency care. 4. Review of R31's electronic medical record (EMR), labeled R31, under the Clinical tab, revealed R31 was readmitted to the facility on [DATE] with a [CONDITION(S)]. An observation was conducted on 02/07/22 at 12:38 PM and there were no emergency [CONDITION(S)] supplies visible in R31's room. An interview was conducted on 02/07/22 at 3:46 PM with LPN1 regarding R31. LPN1 further stated she had not received [CONDITION(S)] care or emergency [CONDITION(S)] training from the facility. An interview and observation were conducted by two surveyors on 02/08/22 at 8:47 AM with LPN4 regarding R31. LPN4 stated there should be a replacement [CONDITION(S)] at R31's bedside. LPN4 stated she received training last year on suctioning and cleaning the [CONDITION(S)] but not on emergency [CONDITION(S)] (in the event R31's [CONDITION(S)] became dislodged). Review of the Daily Assignment Sheet, provided to the survey team by the facility, revealed that the LPNs interviewed were the primary caregivers for R5, R23, R27, and R31. Review facility-provided paper document titled [CONDITION(S)] Training by RT [Respiratory Therapist] dated 10/07/21 (2 hours) revealed six licensed staff members signatures. The content of the material taught was not provided by the facility. An informal interview was conducted on 02/08/22 at 10:30 AM with the Administrator who verified and confirmed the facility's staff had no access to facility's policies and procedures. The Administrator also verified and confirmed facility's policy and procedures were for guidance for staff members including licensed staff. The Administrator confirmed and verified, DON was not able to access facility's policies or procedures. The Administrator further stated the DON was a new employee at the facility and did not have authorization to access the information in the computer. An interview conducted on 02/10/22 at 3:09 PM revealed, Respiratory Therapy (RT), confirmed she provided [CONDITION(S)] education to LPN staff regarding [CONDITION(S)] care on 10/07/21. The RT confirmed only six staff attended the [CONDITION(S)] education class at the facility on 10/07/21. The RT stated, the content of the material covered in the class included: [CONDITION(S)] suctioning, [CONDITION(S)] care, 30-day replacement, manual resuscitation (ambu) for [CONDITION(S)] residents. The RT confirmed emergency [CONDITION(S)] equipment should be kept at resident's bedside and visible, including an ambu bag for manual ventilation. The RT also confirmed and verified she taught LPN staff to reinsert trachs for residents with dislodged or displaced trachs. The RT stated the staff could cover the [CONDITION(S)] stoma with their finger and perform rescue breathing using an ambu bag mask, sealed over resident's nose and mouth to aid with oxygen replacement, for respiratory distress (in the event of an emergency (for displacement or dislodged [CONDITION(S)]).

Based on record review, interview, and facility policy review, the facility failed to ensure care plan interventions regarding emergency [CONDITION(S)] care were developed for one of five residents (Resident (R) 5) sampled for [CONDITION(S)] care. Additionally, the facility failed to ensure care plan interventions regarding emergency [CONDITION(S)] care were implemented for three of five residents (R23, R27, and R31) sampled for [CONDITION(S)] care. On 2/8/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency [CONDITION(S)] supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing [CONDITION(S)] supplies at the bedside in the resident's room and extra [CONDITION(S)] supplies in the nursing supply room, in-servicing nursing staff on location of [CONDITION(S)] supplies and [CONDITION(S)] care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of [CONDITION(S)] supplies, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 2/10/2022. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of facility-provided policy titled, Person-Centered Care Plan, dated 06/21/19 revealed, . A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. Care plans will be . communicated to appropriate staff . Review of the facility-provided policy titled, [CONDITION(S)] Care-Suctioning dated 09/19/20 revealed, . The facility will ensure that residents who need respiratory care, including tracheal suctioning, are provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Review of facility-provided undated policy titled, Oxygen Administration revealed, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of R5's undated Face Sheet provided by the facility revealed R5 was admitted to the facility on [DATE]. R5 was admitted with a [CONDITION(S)]. Review of R5's current Care Plan, located in the electronic medical record (EMR) under the Care Plan tab, revealed R5 had a [CONDITION(S)] and addressed [CONDITION(S)] general care; however, the care plan did not address emergency care and supplies for R5's [CONDITION(S)]. 2. Review of R23's undated Face Sheet, provided by the facility revealed R23 was admitted to the facility on [DATE] with a [CONDITION(S)]. Review of R23's current Care Plan, located in the EMR under the Care Plan tab, revealed R23 had a [CONDITION(S)] and addressed emergency [CONDITION(S)] care as follows: Tube out procedures: Keep extra [CONDITION(S)] [[CONDITION(S)]] tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. R23's care plan did not include the location of emergency supplies. Observations on 02/07/22 at 2:15 PM and 2:42 PM revealed an ambu (self-inflating bag resuscitator) bag hanging on R23's closet door and a red cloth bag hanging on the closet door. An interview and observation on 02/08/22 at 9:16 AM with the ADON revealed R23 had an emergency kit (red cloth bag) that was missing sterile gloves, lubricating jelly, and obturator. 3. Review of R27's undated Face Sheet, provided by the facility revealed R27 was admitted to the facility on [DATE] with a [CONDITION(S)]. Review of R27's current Care Plan, located in the EMR under the Care Plan tab, revealed R27 had a [CONDITION(S)], and the care plan addressed emergency [CONDITION(S)] care as follows: Tube out procedures: Keep extra [CONDITION(S)] tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. R27's care plan did not include the location of emergency supplies. Observations on 02/07/22 at 2:12 PM, 3:22 PM, and 4:44 PM (with LPN3) revealed no emergency supplies available in R27's room. 4. Review of R31's electronic medical record (EMR), labeled R31, under the tab Clinical revealed R31 was admitted to the facility on [DATE] with a re-admitted [DATE]. R31 was readmitted with a [CONDITION(S)]. The Care Plan tab of R31's EMR revealed, R31's care plan included [CONDITION(S)] care (He does exhibit anxiety related to his [CONDITION(S)], suctioning and [CONDITION(S)] care at times) as follows: Administer oxygen as ordered .Change [CONDITION(S)] tube/inner cannula as ordered by physician .Provide education related to [CONDITION(S)] and [CONDITION(S)] care needs .[CONDITION(S)] care as ordered . and addressed [CONDITION(S)] emergency .Tube out procedures: Keep extra [CONDITION(S)] tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help immediately. There was no information regarding [CONDITION(S)] cannula size. Review of R31's Physician Orders, located in R31's EMR under the Orders tab revealed, R31's orders did not include any [CONDITION(S)] information including, physician orders for [CONDITION(S)] size, no physician orders for [CONDITION(S)] care management or emergency management. Review of R31's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempted to review, the Treatment Administration Record (TAR), the results obtained were No Order data found for TREATMENT ADMINISTRATION RECORD. An observation was conducted on 02/07/22 at 12:38 PM, entered R31's room (during the initial tour) there were no emergency [CONDITION(S)] supplies visible in R31's room. During an interview on 02/09/22 at 1:58 PM, the Medical Director confirmed the residents' EMR under care plans should include all aspects of care for [CONDITION(S)] on resident's care plan including [CONDITION(S)] care management, the size of the [CONDITION(S)], suctioning procedure and [CONDITION(S)] emergency management care. An interview was conducted on 02/10/22 at 9:09 PM with MDS Coordinator (MDSC) 1 regarding R5, R23, R27, and R31. MDSC1 stated the [CONDITION(S)] care plans should have included, but not limited to, the following: risk for complications, location of emergency supplies, doctor orders, emergency process if [CONDITION(S)] becomes dislodged. MDSC1 stated R5 did not have comprehensive care plan that addressed the emergency process regarding [CONDITION(S)] care. MDSC1 also stated R23, R27, and R31's care plan had not been implemented. An interview was conducted on 02/10/22 at 9:11 PM with the MDSC2 regarding R5, R23, R27, and R31. MDSC2 confirmed R5's [CONDITION(S)] care plan was not comprehensive. Cross refer to F695.

Based on observation, record review, interview, and review of facility policies titled NSG [CONDITION(S)] Care and [CONDITION(S)] Emergency Bedside Supplies, the facility failed to have emergency [CONDITION(S)] supplies readily available at the bedside for four of five residents (Resident (R) 5, R23, R27, and R31) sampled for [CONDITION(S)] care. On 2/8/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency [CONDITION(S)] supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing [CONDITION(S)] supplies at the bedside in the resident's room and extra [CONDITION(S)] supplies in the nursing supply room, in-servicing nursing staff on location of [CONDITION(S)] supplies and [CONDITION(S)] care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of [CONDITION(S)] supplies, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 2/10/2022. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of the facility's policy titled, NSG [CONDITION(S)] Care, revised 01/02/19, indicated, A replacement [CONDITION(S)] tube must be available at the bedside at all times. The policy further stated, A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Review of facility's undated policy titled, [CONDITION(S)] Emergency Bedside Supplies, revealed, .Each [CONDITION(S)] patient will have the following supplies at the bedside: Spare [CONDITION(S)] tube with obturator of the same make and size currently used, or one size smaller if the same size is not available .syringe .manual resuscitation bag, any necessary connectors to fit patient's [CONDITION(S)] tube. 1. Review of R5's undated Face Sheet provided by the facility revealed R5 was admitted to the facility on [DATE] with a [CONDITION(S)]. Review of R5's Physician Orders, located in the resident's electronic medical record (EMR) under the Orders tab revealed an order dated 10/19/21 of Shiley (brand of [CONDITION(S)]) #6. Upon entering R5's room during the initial tour on 02/07/22 at 11:44 AM, emergency [CONDITION(S)] supplies were not visible. An additional observation by a second surveyor was completed on 02/07/22 at 12:15 PM. During this observation, there were no emergency supplies visible at bedside or in R5's room. An interview was conducted on 02/07/22 at 4:14 PM with LPN2 regarding R5. LPN2 confirmed there were no emergency supplies available in R5's room. LPN2 stated she did not know how to use the emergency [CONDITION(S)] kit. An interview and observation were conducted by two surveyors on 02/08/22 at 9:21 AM with the Assistant Director of Nursing (ADON) regarding R5. The ADON stated the [CONDITION(S)] emergency supplies should be readily visible in the resident's room. The ADON looked through R5's bedside table drawers and found the emergency kit with the following items: three foam [CONDITION(S)] ties, [CONDITION(S)] cleaning kit, Shiley size 7.6 mm (millimeter), Shiley size 6.4 mm, and [CONDITION(S)] mask. The ADON confirmed there were no sterile gloves, lubricating jelly, or obturator in R5's room. Review of a Respiratory Therapy note, provided to the survey team by the facility's Respiratory Therapist (RT), dated 01/06/22 revealed the following for R5: Pt needs #8 [CONDITION(S)] @ [at] bs [bed side] for emergency purposes, a red airway emergency bag . 2. Review of 23's undated Face Sheet provided by the facility revealed R23 was admitted to the facility on [DATE]. R23 was admitted with a [CONDITION(S)]. Review of R23's Physician Orders located in the resident's EMR under the Orders tab, revealed an order dated 10/24/21 of Shiley #6. Upon entering R23's room during the initial tour on 02/07/22 at 2:15 PM, there was an ambu (self-inflating bag resuscitator) bag hanging on the resident's closet door and a red cloth bag hanging on the closet door. At the time of observation, the contents of the red cloth bag were unknown. An additional observation by a second surveyor was completed on 02/07/22 at 2:42 PM. During this observation, R23's had an ambu bag and red cloth bag remained hanging on the closet door. An interview was conducted on 02/07/22 at 4:46 PM with LPN3 regarding R23. LPN3 stated she did not know the location of [CONDITION(S)] emergency supplies for R23. An interview and observation were conducted by two surveyors on 02/08/22 at 9:16 AM with the ADON regarding R23. The ADON confirmed R23 had an ambu bag and emergency kit containing the following supplies: Shiley size 5.0 mm, two Shiley size 6.4, suctioning kit, [CONDITION(S)] cleaning kit, two foam [CONDITION(S)] ties, [CONDITION(S)] mask. The ADON confirmed there were no sterile gloves, lubricating jelly, or obturator in R23's room. 3. Review of R27's undated Face Sheet provided by the facility revealed R27 was admitted to the facility on [DATE]. R27 was admitted with a [CONDITION(S)]. Review of R27's Physician Orders located in the EMR under the Orders revealed an order dated 12/02/21 for Shiley #6. Review of R27's significant change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/20/21 indicated R27 had a Brief Interview for Mental Status (BIMS) of 13 out of 15, which indicated the resident was cognitively intact. Upon entering R27's room during the initial tour on 02/07/22 at 2:12 PM, emergency [CONDITION(S)] supplies were not visible. An additional observation by a second surveyor was completed on 02/07/22 at 3:22 PM for R27. During this observation, the ambu bag was covered by other items and there was no emergency [CONDITION(S)] supplies available. An interview was conducted on 02/07/22 at 4:44 PM with LPN3 regarding R27. LPN3 confirmed there were no emergency supplies available in R27's room. An interview was conducted by two surveyors, with the ADON present, on 02/08/22 at 9:14 AM with R27. The resident stated that she has an ambu bag in her room but does not have the emergency kit. R27 further stated, I have heard other people receiving the red emergency kit, but I didn't get one. Review of a Respiratory Therapy note, provided to the survey team by the facility's RT, dated 01/06/22 revealed the following for R27: Pt needs placed @ bs: red emergency airway bag, #6 [CONDITION(S)] and #4 [CONDITION(S)] for emergency bs equip. An additional RT note, dated 12/17/21 revealed the following for R27: Pt needs emergency bs equipment noted as well as a red emergency airway bag. An additional RT note dated 12/08/21 revealed the following for R27: Pt needs emerg bs equipment - Ambu bag/mask, #6 [CONDITION(S)], #4 [CONDITION(S)] (red airway bag). These items should remain visible and easily accessible. An interview and observation were conducted by two surveyors on 02/08/22 at 9:10 AM with the ADON regarding R27. The ADON stated the [CONDITION(S)] emergency supplies should be readily visible in the resident's room. The ADON searched through R27's drawers, closets, and bathroom. The ADON confirmed the emergency supply kit was not in R27's room nor an obturator but did find the ambu bag behind R27's curtain. 4. Review of R31's electronic medical record (EMR), labeled R31, under the tab Clinical revealed R31 was admitted to the facility on [DATE] with a re-admitted [DATE]. R31 was readmitted with a [CONDITION(S)]. Review of R31's Physician Orders, located in the resident's EMR under the Orders tab revealed, R31 had no information regarding his [CONDITION(S)] including, physician orders for [CONDITION(S)] size, no physician orders for [CONDITION(S)] care management or emergency management and no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R31's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempted to review, the Treatment Administration Record (TAR), the results obtained were No Order data found for TREATMENT ADMINISTRATION RECORD. The Med Review of R31's Med Diag [diagnosis] tab located in the resident's EMR revealed multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was conducted on 02/07/22 at 12:38 PM, entered R31's room (during the initial tour) there were no emergency [CONDITION(S)] supplies visible in R31's room. An interview was conducted on 02/07/22 at 3:46 PM with LPN1 regarding R31. LPN1 confirmed and verified there were no emergency supplies available in R31's room. LPN1 further stated she had not received [CONDITION(S)] care or emergency [CONDITION(S)] training from the facility. An interview and observation were conducted by two surveyors on 02/08/22 at 8:47 AM with LPN4 regarding R31. LPN4 stated there should be a replacement [CONDITION(S)] at R31's bedside. LPN4 confirmed with two surveyors that there was no replacement [CONDITION(S)] in R31's room. LPN4 stated she received training last year on suctioning and cleaning the [CONDITION(S)] but not on emergency [CONDITION(S)] (in the event R31's [CONDITION(S)] became dislodged). LPN4 further stated she would obtain a replacement [CONDITION(S)] from the nursing supply room. An interview and observation were conducted by two surveyors on 02/08/22 at 8:56 AM with the ADON regarding R31. The ADON stated the [CONDITION(S)] emergency supplies should be readily available and visible in the resident's room. The ADON confirmed the emergency supplies were not available or visible. The ADON searched R31's room and found the emergency supply kit in the resident's closet. The ADON confirmed the emergency supply kit contained the following: [CONDITION(S)] cleaning kit, inner cannula size 6.4 mm, and an opened suction catheter. The ADON stated the emergency supply kit should have also contained the following: extra [CONDITION(S)], lubricating jelly, sterile gloves, suction cannula, and obturator. The ADON further stated she would check the nursing supply room for [CONDITION(S)] supplies if the supplies were not available in the resident's room. An interview and observation were conducted by two surveyors on 02/08/22 at 9:04 AM in the supply room with the ADON regarding the nursing supply room on the Gardenia Unit. The ADON stated the supply room did not have the following items: emergency [CONDITION(S)] kits, inner cannulas, sterile gloves, or suctioning catheter kits. An interview was conducted on 02/08/22 at 10:07 AM, with the ADON, Director of Nursing (DON) and Administrator. The DON and Administrator confirmed and verified emergency [CONDITION(S)] equipment was not at bedside for R5, R23, R27, and R31. The DON and Administrator verified emergency [CONDITION(S)] equipment should be visible and available for residents residing at the facility with tracheostomies. An interview was conducted on 02/10/22 at 3:25 PM with the facility's RT regarding R5, R23, R27, and R31. She stated the following emergency equipment should be at bedside, readily visible and accessible: suction machine, ambu bag with mask, same size [CONDITION(S)] and a size smaller, and obturator.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable level of well-being four of five residents (Resident (R) 5, R23, R27, and R31) sampled for [CONDITION(S)] care. Specifically failing to ensure that competent nursing staff were available and trained to care for residents admitted with special care needs such as care for a [CONDITION(S)]. The facility also failed to ensure staff had adequate supplies in the event of an emergency for residents with tracheostomies. On 2/8/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 2/8/2022 at 6:46 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 2/7/2022. The IJ is outlined as follows: The facility failed to ensure four of five residents with a [CONDITION(S)] had the necessary supplies in the event of a life-threatening emergency and failed to train facility nursing staff on the need and use of emergency [CONDITION(S)] kits at the bedside. The facility had five residents with tracheostomies. Upon observations on 2/7/2022 and 2/8/2022, four of the five residents, R5, R23, R27, and R31 did not have necessary emergency [CONDITION(S)] supplies at bedside and additional supplies were not located in the facility. In addition, interviews on 2/7/2022 and 2/8/2022 with nursing staff caring for the residents with tracheostomies (Licensed Practical Nurse (LPN)1, LPN2, and LPN3) revealed a lack of knowledge and training regarding emergency [CONDITION(S)] supplies. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.21(b)(1) -- Develop/Implement Comprehensive Care Plan (F656 Scope/Severity (S/S): K), 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K), 42 CFR 483.35(a)(3)(4)(c) -- Competent Nursing Staff (F726 S/S: K), and 42 CFR 483.70 - Administration (F835 S/S: K). Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.25(i) -- Respiratory/[CONDITION(S)] Care and Suctioning (F695 S/S: K). An Acceptable Removal Plan was received on 2/10/2022. The removal plan included placing [CONDITION(S)] supplies at the bedside in the resident's room and extra [CONDITION(S)] supplies in the nursing supply room, in-servicing nursing staff on location of [CONDITION(S)] supplies and [CONDITION(S)] care, care plan revision, and re-education of administration staff. Through interviews with facility staff, observation of [CONDITION(S)] supplies, clinical record review of revised care plans, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 2/10/2022. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of the facility administrator's job description revealed under the Administrative Functions Plan, develop, organize, implement, evaluate, and direct facility's programs and activities, and Assist in development of written policies and procedures that govern operation of facility . Staff Development Participates in in-service training prior to performing tasks that are new or that employee does not feel competent performing . Competency section Maintains competency & is tested to be competent in: subject to change based on educational needs of staff . Equipment & Supply Functions Ensure that all personnel have proper equipment needed to do their job. Review of the facility-provided paper document titled, Director of Nursing . [DON's] job description revealed the position was, .plan, organize, develop, and direct the overall operations of the Nursing Service Department .to ensure that the highest degree of quality of care is maintained at all times . Facility Administration, including the Administrator and DON, failed to consistently and effectively oversee areas of the facility that were included in their job descriptions. 1. Administration failed to ensure care plan interventions regarding emergency [CONDITION(S)] care were developed for R5; and failed to ensure care plan interventions regarding emergency [CONDITION(S)] care were implemented for R23, R27, and R31. Cross refer to F656. 2. Administration failed to ensure emergency [CONDITION(S)] supplies were readily available at the bedside for R5, R23, R27, and R31. Cross refer to F695. 3 Administration failed to ensure residents with tracheostomies (R5, R24 R37 and R31) were provided nursing care by competent, trained and skilled licensed staff. Cross refer to F726. R5, R23, R27, and R31 were observed on 02/07/22 with lack of emergency tracheostomies supplies at bedside. An interview and observation were conducted by two surveyors on 02/08/22 at 9:04 AM in the supply room with the ADON regarding the nursing supply room on the Gardenia Unit. The ADON stated the supply room did not have the following items: emergency [CONDITION(S)] kits, inner cannulas, sterile gloves, or suctioning catheter kits. An interview was conducted on 02/08/22 at 10:07 AM with the ADON, Director of Nursing (DON) and Administrator. The DON and Administrator confirmed and verified emergency [CONDITION(S)] equipment was not at bedside for R5, R23, R27, and R31. The DON and Administrator verified emergency [CONDITION(S)] equipment should be visible and available for these residents. The Administrator stated, the [CONDITION(S)] supplies were delivered to the facility on Friday and currently are sitting outside on the dock in boxes. The Administrator stated the staff would not know to look for [CONDITION(S)] supplies on the dock outside. An interview was conducted on 02/08/22 at 10:30 AM with the Administrator, DON, and the Regional Director of Operations. The Administrator verified and confirmed the facility's staff had no access to facility's policies and procedures. The Administrator verified and confirmed facility's policy and procedures were for guidance for staff members including licensed staff. The Administrator confirmed and verified, DON was not able to access facility's policies or procedures. The Administrator stated the DON was a new employee at the facility and did not have authorization to access the information in the computer. The Regional Director of Operations stated the staff at the facility did not have access to the policies and procedures due to the company recently purchasing the building and the policies and procedures had not transitioned from the corporate level to the facility level. An interview was conducted on 02/10/22 at 10:06 PM with the Administrator. The Administrator stated he was not aware [CONDITION(S)] supplies were not at R5, R23, R27, and R31's bedside, and was unaware of the lack of [CONDITION(S)] supplies in the nursing supply closet. The Administrator also stated [CONDITION(S)] care was not included in any of the facility quality assurance plans.

Based on record review, review of the 9/19/2020 Performance Improvement Plan (PIP), staff interviews and review of the Administrator's Job Description, the Administrator failed to ensure that staff were performing weekly skin assessments and acting on identified skin concerns; and failed to provide oversight and monitoring of the skin integrity program. The census was 106. On 10/16/2020 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on 10/16/2020 at 1:45 p.m. The noncompliance related to the IJ identified to have existed on 9/13/2020 when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: Resident (R) #1 was readmitted to the facility on [DATE]. On 9/13/2020, staff identified the first three digits of the left foot to be black and discolored. The physician was not notified. On 9/16/2020, staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On 9/19/2020, staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on 10/26/2020. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/20/2020. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Findings include: Review of the facility Job Description, Position Title: Administration revealed: Position summary: create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and [MEDICATION NAME] to patients, residents, and families. The Administrator administers, directs, and coordinates all activities of the Center to assure that the highest degree of quality of care is consistently provided to the residents. Clinical Excellence: 2. Works in close collaboration with the Center Nurse Executive, Medical Director and Director of Rehab to assure high quality clinical outcomes, appropriate level of hospital readmissions, acceptable survey results and the nest possible 5-star rating. The facility failed to provide effective oversight and monitoring of their skin integrity system which resulted in neglect. This system failure included not ensuring that skin assessments were completed routinely by licensed nurses on residents at risk for altered skin integrity. 1. Administration failed to ensure the physician and responsible party were notified of a change in condition for one resident (R) (#1) with left foot necrosis and maggot infestation. Cross refer to F580. 2. Administration failed to ensure care plan interventions were implemented for weekly skin assessments for R#1. Cross Refer to F656. 3. Administration failed to ensure Physician order [REDACTED].#1. Cross refer to F684. 4. Administration failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents with impaired skin integrity. The QAA committee also failed to identify that their established policy for Skin Integrity Management was not being fully operationalized indicated by lack of weekly skin assessments. Cross refer to F867. Review of the Process Improvement Plan for September 2020 revealed a plan for the Skin Protocol Process starting 9/19/2020 (after the incident involving R#1). The facility had a change in Administrator and Director of Nursing (DON) on 8/3/2020. Interview on 9/25/2020 at 2:45 p.m. with the RDO revealed the company purchased the facility in August of 2019. She stated the company was having problems with the previous administrative staff not reporting resident complaints, not reporting broken equipment, etc. The company hired a new Administrator and DON in August 2020. An interview was conducted on 10/13/2020 at 3:25 p.m. with the Administrator who stated she became aware of R#1's left foot on 9/19/2020 after receiving a call from the DON. The Administrator stated she did not consider when R#1 was found with necrotic toes that were infested with maggots to be abuse or neglect. In a telephone interview with the Owner of the facility on 10/28/2020 at 2:15 p.m., he stated he purchased the facility in August 2019 and lives out of state. He stated his biggest challenge was finding good people in leadership, particularly administrative. He stated he tried to give the previous Administrator, DON, and other managers a fair chance because it takes time to identify people's strengths and weaknesses. However, he became aware this facility did not have good leadership and needed a change. A leadership change was made in August 2020. Further interview on 11/3/2020 at 2:45 p.m. with the Administrator revealed that the outcome for R#1 would have been different if the facility had a unit manager in place, weekly skin check where done consistently, and baths being completed consistently. The Administrator stated after 8/3/2020 the facility had no unit manager, no leadership/management to make sure that the staff were consistent with following process. The facility implemented the following actions to remove the IJ: 1. On 10/19/2020 a Root Cause Analysis (RCA) of the skin integrity system breakdown was completed by Regional Director of Operation, Regional Director of Clinical Services, Medical Director, Administrator and Director of Nursing. Documentation of analysis was put on the RCA Tool and will be included in the next Quality Assurance Performance Improvement (QAPI) meeting. 2. Regional Director of Operations re-educated the Administrator on her job description and on the identification, reporting, investigation, analysis, and prevention of adverse events; and the development, implementation, and evaluation to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents on October 16, 2020. 3. Administrator hosted an AD HOC Quality Assurance Performance Improvement meeting on October 17, 2020 with the Medical Director, Director of Nursing, Regional Director of Clinical Services and Director of Operations to review the center's Skin Integrity Management Program and the performance improvement measures outlined in this document. 4. Regional Director of Operations, Regional Clinical Services Director, Medical Director Administrator, and Director of Nursing reviewed wound tracking logs in the last 30 days to identify prevention opportunities, investigation, and s on October 16, 2020. 5. Administrator identified Improvement Activities and Performance Improvement Projects (PIP) based on trends and identified potential opportunities upon completion of the adverse events reviewed on October 16, 2020. PIP plans and RCA documents will be maintained as part of the QAPI process 6. A review of skin assessment schedules and wound tracking logs was completed on October 16, 2020 by the clinical team consisting of MDS, Nurse Managers, Director of Clinical Services, ADON). Audit review will be documented on the Skin Assessment and Wound Log Audit Tool. 7. New skin assessments were completed on residents (99 of 102 with 3 refusals) on October 16 - 17, 2020 to identify any wound related concerns. Any new concerns identified were documented on the Body Audit Tool and will be reported to the MD, a plan of care will be implemented, and families will be notified. 8. MDS Nurse (s) reviewed and updated care plans on residents identified with wounds as of October 18, 2020. Recommendations will be reviewed at the next scheduled regular Quality Assurance Performance Improvement meeting. 9. Administrator educated center staff (RNs 5 of 6 -83%; LPNs 22 of 25 -88%; CNAs 35 of 39 -90%/ Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%; Hskp 10 of 10-100%; Kitchen 10 of 10- 100%; Therapy 4 of 7; Maintenance 2 of 2; Administration 5 of 6- 83%; Activities 2 of 2- 100%; NP 1 of 1- 100%/) on systems and processes to engage staff participation in identifying improvement opportunities and participating in performance improvement teams on October 16 - 17, 2020. Teleconference/phone in-servicing was provided to RN 1, LPNs 3 on October 19, 2020. Employees on leave of absence FMLA¿ (3 LPNs and 3 CNAs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on¿ site education. 10. On 10/19/2020 Regional Director of Operations educated licensed nurses (RNs 5 of 6 - 83%; LPNs 22 of 25 -88%/ Agency: LPNs 6 of 7- 86%; on putting physician orders [REDACTED]. Teleconference/phone in¿ servicing was provided to RN 1, LPNs 3 on October 19, 2020. Employees on leave of absence FMLA- (3 LPNs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on¿ site education. 11. The Regional Clinical Services Director provided re-education on October 16, 2020, to the Administrator and Director of Nursing on the Skin Integrity Management Program. 12. The Assistant Director of Nursing re-educated staff (RNs 5 of 6 -83%; LPNs 22 of 25 - 88%; CNAs 35 of 39 -90%/ Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%) from October 16 - 17, 2020 on the Skin Integrity Management Program. Teleconference/phone in-servicing was provided to RN 1, LPNs 3, CNAs 3 on October 19, 2020. Employees on leave of absence FMLA- (3 LPNs and 3 CNAs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 13. Nurse Managers will discuss adverse events (related to wounds)/skin assessments with the Administrator daily as part of the Morning Meeting process. S (sic) will be implemented as needed 14. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the Medical Director and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A Root Cause Analysis (RCA) was completed on 10/19/2020 and revealed the Administrator, Medical Director, DON, Director of Operations and Regional Director of Clinical Services completed the RCA. The RCA revealed that a skin check was completed on R#1 on 9/13/2020 and agency nurse failed to notify the Physician, family, or facility leadership of discovery of discolored toes, no plan of care initiated. Review of Corrective Actions are ongoing. 2. Review of the facility in-service record dated 10/16/2020 revealed the Administrator received education on her job description, identification, reporting, investigation, analysis and prevention of abuse events, and evaluation of corrective action. Also verified by interview with the Administrator on 11/4/2020 at 2:27 p.m. 3. Review of the QAPI sign-in sheet dated 10/17/2020 revealed the Administrator, Medical Director, Regional Director of Clinical Service, Regional Director of Operations, and Director of Nursing in attendance. The committee reviewed seven Immediate Jeopardy citations related to wound care, notification processes, quality of care, administration, QAPI, and care plans. Topics: wounds (skin assessments, protocols, treatments, schedules, processes, notifications), CNA bath schedule & daily skin checks, notifications, key policies, scopes of practice (licensed nurses/CNAs), care plans, and head-to-toe assessments. Also verified by interview with the DON on 10/20/2020 at 2:30 p.m. 4. Review of the facility in-service record dated 10/16/2020 revealed the Administrator, RDO, RDCS, and the Medical Director reviewed the Wound Tracking Log (wound location, wound type, PU status/date, PU stage, interventions, treatment, progress, and plan): 9/24/2020, 10/2/2020, 10/9/2020, 10/16/2020, and 10/23/2020. The Skin Assessment & Wound Audit Tool dated 10/16/2020: 12 residents reviewed with skin conditions identified, wound logged, care plan updated; and comments/follow-up as indicated. 5. Review of facility documents revealed a Process Improvement Plan (PIP) was developed on 10/16/2020 addressing the noncompliance identified. 6. Review of the Wound Tracking Log identified 12 residents with skin conditions, wound log in place, and care plan updated. Skin audit tool & schedules for skin assessment listed. 7. Review of the daily census sheet dated 10/16/2020 revealed a total census of 101. Review of the IMG_0189.jpeg (facility using to document skin assessments) revealed three residents refused the skin assessment. Review of the total number of IMG_0189.jpeg sheets completed was 102 including the three residents that refused. SBAR (Situation, Background, Appearance, Review/Notify) were completed for all identified skin concerns with family and physician notification documented. There were no further concerns related to abuse or neglect. During an interview on 11/4/2020 at 10:35 a.m., the Regional Director of Clinical Services (RDCS) stated the facility document titled IMG_0189.jpeg are Body Audits. The change in condition (CIC) and SBAR are the same assessment tools. The task started on 10/16/2020 and was completed on 10/17/2020. She stated the LPN's and MDS Coordinators completed 99 resident body audits and three residents refused the skin assessment. She stated the Body Audits were compared with the previous skin sweep (9/22/2020 and 9/23/2020) and the last two skin checks in the electronic health record. They reviewed the documentation for progress notes, notification of the Physician and responsible party, orders that were carried out, completion of the CIC/SBAR and an update of the care plan. 8. Review of the Wound Management Tracking Tool dated 10/18/2020 revealed 11 resident care plans were reviewed and updated if needed. R#12, R#25, and R#31 had updated care plans with no concerns. 9. Review of facility in-service records dated 10/16/2020 through 10/19/2020 revealed 7 RN's, 31 LPN's, 52 CNA's, 10 Housekeeping, 10 Dietary, 4 Therapy, 2 Maintenance; 5 Administration, 2 Activities, and 1 NP received education on identifying opportunities for improvement and participating on improvement teams. Also verified the above in-services via the following staff interviews on 10/26/2020 at 11:45 a.m. with RN JJ; 11/2/2020: 6:42 a.m. with LPN UU, 6:45 a.m. with CNA WWW, 6:48 a.m. with CNA BBBB, 6:52 a.m. with CNA OOO, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; 11/4/2020: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; 11/5/2020: 1:50 p.m. with CNA CCCC and 2:53 p.m. with CNA EEEE; 11/6/2020 at 11:01 a.m. with RN KK; and 11/10/2020 at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Also verified the above in-services via the following staff interviews on 11/8/2020: 11:35 a.m. with Floor Tech NNNN, 11:41 a.m. with HK QQQQ, 11:52 a.m. with Account Manager MMMM, 11:57 a.m. with the Director of Marketing, 12:05 p.m. with the Maintenance Director, 1:00 p.m. with the dietary aide UUUU, 1:02 p.m. with Staff VVVV, and 1:05 p.m. with dietary aide WWWW. 10. Review of facility in-service record dated 10/16/2020 revealed 7 RN's and 32 LPN's received education on how to enter physician orders [REDACTED]. Also verified the above in-services via the following staff interviews on 10/26/2020 at 11:45 a.m. with RN JJ; 11/2/2020: 6:42 a.m. with LPN UU, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; 11/4/2020: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; 11/6/2020 at 11:01 a.m. with RN KK; and 11/10/2020 at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 11. Review of the facility in-service records dated 10/16/2020 revealed the Administrator and DON were educated on skin assessments, implementation of treatment, monitoring and notification. Also verified by interview with the Administrator on 11/4/2020 at 2:27 p.m. and the DON on 10/20/2020 at 2:30 p.m. The following policies were reviewed: Pressure Ulcer/ Skin Breakdown - Clinical Protocol, Wound Care, and Weekly Skin Check Form. 12. Review of facility in-service record dated 10/16/2020 revealed 7 RN's, 31 LPN's, and 52 CNA's received education on the Skin Integrity Management Program. The following policies were reviewed: Pressure Ulcer/ Skin Breakdown - Clinical Protocol, Wound Care, and Weekly Skin Check Form. Also verified the above in-services via the following staff interviews on 10/26/2020 at 11:45 a.m. with RN JJ; 11/2/2020: 6:42 a.m. with LPN UU, 6:45 a.m. with CNA WWW, 6:48 a.m. with CNA BBBB, 6:52 a.m. with CNA OOO, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; 11/4/2020: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; 11/5/2020: 1:50 p.m. with CNA CCCC and 2:53 p.m. with CNA EEEE; 11/6/2020 at 11:01 a.m. with RN KK; and 11/10/2020 at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 13. Review of facility documents revealed incident reports were reviewed daily starting 10/20/2020 with notations and follow up. 14. Review of the QAPI Meeting Minutes dated 10/23/2020 revealed the RDO, RDCS, ADON, Admission Director, Activities Director, Environmental Service Manage, Maintenance, Marketing Director, MDS Coordinators, and the Dietary Manager were in attendance. Specific Subject Matter Topics: IJ Issuance and Abatement Plan, skin audits, wound log, reviewed the purpose of the weekly at-risk meeting, concerns identified, communication, policy review, QAPI schedule, and staff education. Review of the QAPI Meeting Minutes dated 10/30/2020 signed by the Medical Director, Administrator, DON, Admission Director, Wound Nurse, ADON, Activities Director, Environmental Service Manager, Maintenance, Marketing Director, RN Supervisors, MDS Coordinators, and the Dietary Manager. Specific Subject Matter Topics: audits, skin integrity, baths, staffing, new PIP (process improvement plan). Review of a typed statement on the facility's letterhead revealed daily and weekly skin audits (Clinical Skin System Audit Tool) results were reviewed by the administrator with physician and QAPI committee attendees on 10/17/2020, 10/23/2020 and 10/30/2020. Audit results will continue to be reviewed at each subsequent QAPI meeting. Reviewed by phone with Medical Director on 10/23/2020; all other communication done in person. Signed by the Administrator. Interview on 11/4/2020 at 2:27 p.m. with the Administrator revealed she reviewed each of the facility audit reports and reports to the Medical Director and Interdisciplinary Team during QAPI meetings.

Based on staff interviews, record review, and review of the Quality Assurance Performance Improvement (QAPI) Policy and Procedure, the facility failed to have an effective Quality Assurance process that identified concerns related to the care and management of residents with impaired skin integrity. The facility census was 106. On 10/16/2020 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on 10/16/2020 at 1:45 p.m. The noncompliance related to the IJ identified to have existed on 9/13/2020 when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: Resident (R) #1 was readmitted to the facility on [DATE]. On 9/13/2020, staff identified the first three digits of the left foot to be black and discolored. The physician was not notified. On 9/16/2020, staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On 9/19/2020, staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on 10/26/2020. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/20/2020. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Finding included: Review of the undated policy titled Quality Assurance and Performance Improvement (QAPI) Policy and Procedure revealed the following: Policy: It is the policy of the facility to maintain a Quality Assurance and Performance Improvement (QAPI) program. The program will be ongoing and comprehensive and will address the full range of care and services provided by the facility. The program will: a. Address all systems of care and management practices. b. Include clinical care, quality of life and resident choice. Procedure: 3. Committee d. The committee must develop and implement appropriate plans of action to correct identified quality deficiencies. e. The committee must regularly review and analyze data, including data collected under the QAPI program . It must act on available data to make improvements. A review of the Quality Assurance (QA) committee meeting sign in sheets revealed that the members of the committee included the Administrator, Medical Director, Director of Nursing (DON), Activities Director, Wound Care Nurse, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator, Housekeeping Director, Dietary Manager, Maintenance Director, Accounts Manager, and Registered Nurse (RN) Supervisor. Review of the Process Improvement Plan for September 2020 revealed a plan for the Skin Protocol Process starting 9/19/2020 (after the incident involving R#1). Root cause and factors identified were lack of weekly skin assessments, lack of a bathing schedule and processes, lack of system to orient staff on skin integrity and failure of facility nursing staff to follow Physician Orders. No other QAPI plans were provided related to issues identified prior to 9/19/2020 concerning residents' skin integrity. During an interview on 10/30/2020 at 1:20 p.m., the Medical Director (MD) stated the deficient practices which lead to the Immediate Jeopardy assessed against the facility revealed a breakdown of several facility systems which needed to be addressed immediately, including a failure to perform complete and appropriate physical assessments by nursing and medical staff, failure to notify nursing management, medical staff, and family of changes in condition, failure to provide quality care to residents, failure to educate clinical staff on importance of the physical assessment and the types of assessments, failure to follow-up with significant findings of the physical assessment, and the failure to identify, evaluate and correct areas of concern related to resident care and service. Interview on 11/3/2020 at 2:45 p.m. with the Administrator revealed that after 8/3/2020, the facility had no unit manager, no leadership/management to make sure that the staff were consistent with following process. Cross refer to F600 and F684. The facility implemented the following actions to remove the IJ: 1. Regional Director of Operations re-educated the Administrator on the Quality Assurance Performance Improvement process to include systematic identification, reporting, investigation, analysis, and prevention of adverse events·; and documentation demonstrating the development, implementation, and evaluation of s or performance improvement activities on October 16, 2020. 2. Regional Director of Operations, Director of Clinical Operations, Clinical Quality Specialist, Medical Director, Administrator, and Director of Nursing reviewed the Quality Assurance Performance Improvement process and discussed success/barriers for all improvement activities and performance improvement projects to ascertain support, resources, and breakthrough ideas on October 16, 2020. 3. Administrator hosted a Quality Assurance Performance Improvement (QAPI) AD HOC meeting on October 17, 2020 with the Medical Director on the center's Skin Integrity Management Program and the performance improvement measures outlined in this document. 4. On 10/18/2020 the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Quality Assurance and Performance Improvement. No policy changes or recommendations were made as a result of this review. 5. Data collected as a result of the Root Cause Analysis was addressed in QAPI 6. On 10/17/2020 the Director of Clinical Services reviewed residents' skin assessment schedule to identify areas of concern. Findings of the review were documented on the Skin Audit Tool. 7. Regional Director of Clinical Services and Director of Nursing reviewed skin sheets with wound nurse and created Wound Tracking Log to identify and track wound treatments on September 24, 2020. 8. Administrator identified Improvement Activities and Performance Improvement Projects based on trends and identified potential opportunities upon review of the Wound Tracking Log on October 16, 2020. 9. On October 15, 2020, Wound Physician assessed 100% of the identified residents on the Wound Tracking Log to treat and make further recommendations as needed. 10. Regional Director of Clinical Services reviewed center's clinical meeting process on identification of clinical concerns by October 16, 2020. Findings of her review were noted and shared with the Administrator 11. Administrator educated staff (RNs 5 of 6 -83%; LPNs 22 of 25 -88%; CNAs 35 of39 - 90%/ Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%; Hskp 10 of 10-100%; Kitchen 10 of 10- 100%; Therapy 4 of 7; Maintenance 2 of 2; Administration 5 of 6- 83%; Activities 2 of 2- 100%; NP 1 of 1- 100%/) to facilitate understanding of Quality Assurance Performance Improvement program and processes, and systems to engage staff in participation in identifying improvement opportunities and participating in performance improvement teams on October 16, 2020. Teleconference/phone in-servicing was provided to RN 1, LPNs 3, CNAs 3 on October 19, 2020. Employees on leave of absence FMLA- (3 LPNs and 3 CNAs), vacation (1 RN) or agency staff will be re¿ educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 12. Regional Director of Clinical Services worked with purchasing to ensure we have appropriate treatment supplies in house to appropriately treat or prevent wounds. 13. Quality Assurance Performance Improvement (QAPI) AD HOC meeting held on October 17, 2020 to review with the Medical Director the policies on Skin Integrity Management, Following Physician orders [REDACTED]. 14. Administrator will host Quality Assurance Performance Improvement meeting weekly for four weeks to ensure systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation to support the development, implementation, and evaluation of performance improvement activities. 15. Licensed Nurses will complete skin assessments weekly and report findings to the Director of Nursing. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the facility in-service records dated 10/16/2020 revealed the Administrator and the DON received educations on system identification, reporting, investigation, analysis and prevention to address adverse events, tracking and trending, outcomes, and evaluation of corrections and improvement. Quality of Care and QAPI Policy and Procedure was reviewed. Also verified by interview with the Administrator on 11/4/2020 at 2:27 p.m. and the DON on 10/20/2020 at 2:30 p.m. 2. Review of the QAPI Committee Meeting Sign-In Sheet dated 10/17/2020 revealed an Ad/Hoc meeting with the DON, Administrator, Medical Director, RDO, and RDCS. 3. The committee reviewed seven Immediate Jeopardy citations related to wound care, notification processes, quality of care, administration, QAPI, and care plans. Topics: wounds (skin assessments, protocols, treatments, schedules, processes, notifications), CNA bath schedule & daily skin checks, notifications, key policies, scopes of practice (licensed nurses/CNAs), care plans, and head-to-toe assessments. 4. Review of the Internal Policy Review Form dated 10/18/2020 revealed facility policy titled Quality Assurance and Performance Improvement was reviewed with no revisions as indicated by signatures of the Administrator, Director of Operations, Director of Clinical Services and Medical Director (via teleconference). Interview with the Medical Director on 10/30/2020 at 1:38 p.m. revealed the policy was reviewed and did not need any changes. 5. Review of the QAPI Committee Meeting Sign-In Sheet dated 10/23/2020 revealed a meeting with the DON, Administrator, Medical Director, RDO, and RDCS. Topics included IJ issuance and abatement plan, audits, weekly at-risk meetings, communication, policy review, and education. The above QAPI meeting attendance was also verified by interview with the DON on 11/2/2020 at 2:33 p.m. 6. Review of the Skin Audit Tool dated 10/17/2020 signed by the Director of Clinical Services revealed seven residents with missing assessments and shift. A schedule was reestablished with hall, shift, and day of the week. R#36 had a skin assessment scheduled for 11/6/2020. During observation and interview on 11/6/2020 at 11:30 a.m., LPN MMM completed the skin assessment for R#36 without concern. The schedule was posted at the nurse's station and in the User Defined Assessment (UDA) of the electronic health record. R#25 had a skin assessment scheduled for 11/10/2020. During observation and interview on 11/10/2020 at 10:10 a.m., LPN VV completed the skin assessment for R#25 without concern. The schedule was posted at the nurse's station and in the User Defined Assessment (UDA) of the electronic health record. 7. Review of the Wound Tracking Logs dated 10/30/2020, 10/23/2020, 10/16/2020, 10/9/2020, 10/2/2020, and 9/24/2020 revealed wounds were reviewed by the DON and Wound Treatment Nurse. This was verified by interview with LPN NN on 11/5/2020 at 4:29 p.m. 8. Review of facility documents revealed a Process Improvement Plan (PIP) was developed on 10/16/2020 addressing the skin protocol process. 9. Review of the Wound Physician Notes dated 10/15/2020 and 10/16/2020 revealed the Wound Physician assessed all residents on the Wound Tracking Log. Residents were also assessment for the need and use of wedges, heel protectors, and barrier cream. 10. Review of the Daily Clinical Meeting Review dated 10/16/2020 revealed the RDCS observed the clinical meeting to ensure it was being held in accordance with company standards. Additional recommendations were made to review bath sheets for any new skin conditions. 11. Review of facility in-service records dated 10/16/2020 through 10/19/2020 revealed 7 RN's, 31 LPN's, 52 CNA's, 10 Housekeeping, 10 Dietary, 4 Therapy, 2 Maintenance; 5 Administration, 2 Activities, and 1 NP received education on understanding the QAPI Program and Processes. Also verified the above in-services via the following staff interviews on 10/26/2020 at 11:45 a.m. with RN JJ; 11/2/2020: 6:42 a.m. with LPN UU, 6:45 a.m. with CNA WWW, 6:48 a.m. with CNA BBBB, 6:52 a.m. with CNA OOO, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; 11/4/2020: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; 11/5/2020: 1:50 p.m. with CNA CCCC and 2:53 p.m. with CNA EEEE; 11/6/2020 at 11:01 a.m. with RN KK; and 11/10/2020 at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Also verified the above in-services via the following staff interviews on 11/8/2020: 11:35 a.m. with Floor Tech NNNN, 11:41 a.m. with HK QQQQ, 11:52 a.m. with Account Manager MMMM, 11:57 a.m. with the Director of Marketing, 12:05 p.m. with the Maintenance Director, 1:00 p.m. with the dietary aide UUUU, 1:02 p.m. with Staff VVVV, and 1:05 p.m. with dietary aide WWWW. 12. Review of the invoice documentation for 9/21/2020 through 9/27/2020 and 10/19/2020 through 10/25/2020 revealed supplies ordered including bariatric heel protectors, heel protectors, and positioning wedges. 13. Interview with the Medical Director on 10/30/2020 at 1:38 p.m. revealed the polices on Skin Integrity Management, Following Physician Orders, and Abuse were reviewed in the above 10/17/2020 QAPI meeting. 14. Review of the QAPI Meeting Minutes dated 10/23/2020 revealed the RDO, RDCS, ADON, Admission Director, Activities Director, Environmental Service Manage, Maintenance, Marketing Director, MDS Coordinators, and the Dietary Manager were in attendance. Specific Subject Matter Topics: IJ Issuance and Abatement Plan, skin audits, wound log, reviewed the purpose of the weekly at-risk meeting, concerns identified, communication, policy review, QAPI schedule, and staff education. Review of the QAPI Meeting Minutes dated 10/30/2020 signed by the Medical Director, Administrator, DON, Admission Director, Wound Nurse, ADON, Activities Director, Environmental Service Manager, Maintenance, Marketing Director, RN Supervisors, MDS Coordinators, and the Dietary Manager. Specific Subject Matter Topics: audits, skin integrity, baths, staffing, new PIP (process improvement plan). Review of a typed statement on the facility's letterhead revealed daily and weekly skin audits (Clinical Skin System Audit Tool) results were reviewed by the Administrator with Physician and QAPI committee attendees on 10/17/2020, 10/23/2020 and 10/30/2020. Audit results will continue to be reviewed at each subsequent QAPI meeting. Reviewed by phone with Medical Director on 10/23/2020; all other communication done in person. Signed by the Administrator. Interview on 11/4/2020 at 2:27 p.m. with the Administrator revealed she reviewed each of the facility audit reports and reports to the Medical Director and Interdisciplinary Team during QAPI meetings. 15. Review of the Clinical Skin System Audit Tools dated 11/2/2020, 11/1/2020, 10/31/2020, 10/30/2020, 10/28/2020, 10/27/2020, 10/26/2020, 10/25/2020, 10/24/2020, 10/23/2020, 10/22/2020, 10/21/2020, 10/20/2020, and 10/19/2020 revealed skin assessments were completed and findings reported to the DON. Also verified by interview with the DON on 11/2/2020 at 2:33 p.m.

Based on observations, record review, review of the facility policies titled Changes in a Resident's Condition or Status and Resident Rights Under Federal Law, and family/staff interviews, the facility failed to notify the Physician and Responsible Party (RP) of a change in condition for one resident (R) (#1) for left foot necrosis with maggot infestation of 36 sampled residents. On 10/16/2020 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on 10/16/2020 at 1:45 p.m. The noncompliance related to the IJ identified to have existed on 9/13/2020 when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: R#1 was readmitted to the facility on [DATE]. On 9/13/2020, staff identified the first three digits of the left foot to be black and discolored. The Physician was not notified. On 9/16/2020, staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On 9/19/2020, staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on 10/26/2020. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/20/2020. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Findings include: Review of the facility policy titled Changes in a Resident's Condition or Status revised 6/2013 revealed: The facility shall promptly notify the resident, his/her attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Procedures/Responsibilities/Actions: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or on-call Physician when there has been 1.2 A discovery of injuries of unknown origin and 1.4 A significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a decline or improvement in the resident's status. 3. Unless instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative. 4. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. Review of the policy titled Resident Rights Under Federal Law effective 8/2019 indicated 7.2.14. Notification of changes. 7.2.14.1 A facility must immediately inform the resident, consult with the resident's Physician, and notify, consistent with his/her authority, resident representative(s), where there is: 7.2.14.1.2. A significant change in the resident's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A review of the Admission Record (face sheet) for R#1 revealed the resident was admitted to the facility on [DATE] and a readmission on 12/19/2017 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] for R#1 revealed a Brief Interview for Mental Status (BIMS) was coded as 3 out of 15, which indicated severe cognitive impairment. Section M revealed the resident high risk for pressure ulcer; and had no pressure ulcers and zero venous ulcer, or arterial ulcers. Review of the Electronic Medical Record (EMR) Skin Check dated 9/13/2020 revealed: The left foot, the first three digits of foot are black and discolored. Patient complained of pain and discomfort in foot. Patient given something for pain. Another nurse was called into to look. There is no evidence that the Physician or family was notified. A review of the EMR Wound/Skin Note dated 9/16/2020 revealed: Asked to observe left foot (the writer). First three toes of left foot, with necrotic, devitalized tissue, with small open areas. A telephone order received for the Nurse Practitioner (NP) for [MEDICATION NAME] daily, have the Wound Physician see the resident and for Arterial Doppler study ASAP (as soon as possible). The telephone order was transposed to the EMR although there was no evidence of follow through for these orders. During an interview on 9/23/2020 at 10:58 a.m., family of R#1, who is the Power of Attorney (POA), stated he did not receive any calls from the facility on the 9/13/2020 or on 9/16/2020 regarding the condition of the resident's left foot. He stated on 9/19/2020 he received a call from the facilities NP informing him that R#1 had to be sent out to the hospital because her toes were black. He stated around 9:30 p.m. he received a call from a Physician who informed him that R#1's left foot was really bad and would have to be amputated. During an interview on 9/29/2020 at 1:13 p. m., Licensed Practical Nurse (LPN) OO stated she assessed R#1's left foot on 9/16/2020. LPN OO stated the toes on the left foot were necrotic. LPN OO stated she did not notify the Wound Physician as ordered by the NP. LPN OO also stated she did not notify the family on 9/16/2020 of the condition of R#1's left foot. An interview on 9/30/2020 at 1:35 p.m. with LPN TT revealed she assessed R#1's left foot on 9/13/2020. Upon assessment, the resident's left foot the third toe looked like a raisin (wrinkled) and the toe looked like it was going to fall off. The second toe on the left foot was purple. LPN TT stated she did not notify the Physician, family, or the Director of Nursing (DON). LPN TT stated did not know where to look for the family or the Physician's number. She stated she did have the DON's number but failed to call the DON. LPN TT stated it was poor judgement for not notifying the Physician and the family. An interview was conducted on 10/8/2020 at 8:50 a.m. with the Wound Physician AA who stated he makes rounds in the facility every Thursday. He also stated the wound nurse communicates to him any new residents that need to be seen. Wound Physician AA stated he was in the facility on 9/17/2020 and he was not asked to assess R#1 left foot. Cross refer to F600. The facility implemented the following actions to remove the IJ: 1. RI (Resident) # 1 no longer resides at the facility. 2. On 10/18/2020 the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Notification of Change. No policy changes or recommendations were made as a result of this review. 3. On 10/17/2020 the Director of Clinical Services reviewed residents' skin assessment schedule to identify areas of concern. Findings of the review were documented on the Skin Audit Tool. 4. A second set of whole house (99 of 102 residents with 3 refusals) skin assessments was completed on October 16 -17 (2020) by the center charge nurses to identify any additional skin concerns. Any new concerns identified will be documented on the body audit sheet, reported to the MD (Physician) and any orders obtained will be implemented. Plan of care will be updated, and responsible parties will be notified 5. On October 16 - 17, 2020 the Director of Clinical Services reviewed all body audit sheets for change in condition, and to validate MD and RP notification. Review was documented on the Skin Audit Tool and shared with the Administrator and Director of Nursing. 6. Nursing Staff (RNs 5 of 6 -83%; LPNs 22 of 25 -88%; CNAs 35 of 39 -90%/ Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%) was educated by the Administrator on the importance of MD notification, implementation of MD orders, and RP notification and alerting the charge nurse of change in condition on October 16- 19, 2020. Teleconference/phone in-servicing was provided to RN 1, LPNs 3, CNAs 3 on October 19, 2020. Employees on leave of absence FMLA- (3 LPNs and 3 CNAs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 7. Charge nurses will complete weekly skin checks in electronic medical record to verify the current status of resident's skin. Any new areas identified will be reported to the MD, orders obtained will be implemented and communicated to the wound nurse, DON and clinical team via electronic medical record Risk Management, 24 hr. report, and/or Hey Wound Team Notice. The care plan will be updated, a Change in Condition documentation will be completed, and RP will be notified. 8. Certified Nursing Assistance will complete baths per the bath schedule. Documentation of baths will be documented in the electronic medical record under the activities of daily living. Any skin impairments will be documented utilizing the coding provided in the EMR and will be reported to the charge nurse. Any new areas identified will be reported to the MD, orders obtained will be implemented and communicated to the wound nurse, DON and clinical team via electronic medical record Risk Management, 24 hr. report, and/or Hey Wound Team Notice. The care plan will be updated, a Change in Condition documentation will be completed, and RP will be notified. 9. The Director of Nursing and nursing management team (consisting of Unit Managers, ADON (Assistant Director of Nursing), MDS, RN Supervisors) will review weekly bath schedule and skin notation, skin checks during daily clinical meetings and will verify Physician notification, orders implementation per Physician Orders and that family has been notified of updated plan of care. Reviewed results will be documented on the Clinical Meeting Skin System Audit Tool. 10. Residents with pressure ulcers and significant wounds will be assessed and followed by the visiting wound Physician and orders will be implemented by the center. Any changes made by the Wound Physician will be communicated to the resident's family and documented in the progress note in ELECTRONIC MEDICAL RECORD. DON and Nurse Managers will review wound reports and skin checks during the weekly at the clinical risk meeting to ensure the plan of care of residents with wounds and pressure ulcers are being followed. 11. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting weekly for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the Physician and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the facility census list revealed billing stopped for R#1 on 9/26/2020 which was her discharge date . Interview with the Family of R#1 on 11/5/2020 at 9:30 a.m. revealed that the resident was discharged from the hospital and currently resides at a different nursing home. 2. Review of the Internal Policy Review Form dated 10/18/2020 revealed facility policy titled Change in Resident's Condition or Status was reviewed with no revisions as indicated by signatures of the Administrator, Director of Operations, Director of Clinical Services and Medical Director (via teleconference). Interview with the Medical Director on 10/30/2020 at 1:15 p.m. revealed the policy was reviewed and did not need any changes. 3. Review of the Skin Audit Tool dated 10/17/2020 signed by the Director of Clinical Services revealed seven residents with missing assessments. A schedule was reestablished with hall, shift, and day of the week. R#36 had a skin assessment scheduled for 11/6/2020. During observation and interview on 11/6/2020 at 11:30 a.m., LPN MMM completed the skin assessment for R#36 without concern. The schedule was posted at the nurse's station and in the User Defined Assessment (UDA) of the electronic health record. R#25 had a skin assessment scheduled for 11/10/2020. During observation and interview on 11/10/2020 at 10:10 a.m., LPN VV completed the skin assessment for R#25 without concern. The schedule was posted at the nurse's station and in the User Defined Assessment (UDA) of the electronic health record. 4. Review of the daily census sheet dated 10/16/2020 revealed a total census of 101. Review of the IMG_0189.jpeg (facility using to document skin assessments) revealed three residents refused the skin assessment. Review of the total number of IMG_0189.jpeg sheets completed was a 102 including the three residents that refused. SBAR (Situation, Background, Appearance, Review/Notify) were completed for all identified skin concerns with family and Physician notification documented. R#15, R#29, R#31, R#37, R#38, and R#39 had findings from the skin assessments reported timely to the family and Physician. During an interview on 11/4/2020 at 10:35 a.m., the Regional Director of Clinical Services (RDCS) stated the facility document titled IMG_0189.jpeg are Body Audits. The change in condition (CIC) and SBAR are the same assessment tools. The task started on 10/16/2020 and was completed on 10/17/2020. She stated the LPN's and MDS Coordinators completed 99 resident body audits and three residents refused the skin assessment. She stated the Body Audits were compared with the previous skin sweep (9/22/2020 and 9/23/2020) and the last two skin checks in the electronic health record. They reviewed the documentation for progress notes, notification of the Physician and responsible party, orders that were carried out, completion of the CIC/SBAR and an update of the care plan. 5. Review the of the statement on the facility letterhead dated 10/17/2020 signed by the RDCS revealed the Body Audits from the house skin sweep were reviewed. The RDSC noted six residents with new areas. The statement further stated that the Physician and RP were notified. The findings were reported to the Administrator and DON. Finding were shared during the AD HOC Committee meeting. An interview was conducted on 11/4/2020 at 11:19 a.m. with the RDCS. She confirmed review of all body audit sheets for change in condition, and to validate Physician and RP notification. The information was communicated to the Administrator and the DON. 6. Review of facility in-service record dated 10/16/2020 revealed 7 RN's, 31 LPN's, one Nurse Practitioner (NP) and 52 CNA's received education on notification of change and order entry. Also verified the above in-services via the following staff interviews on 10/26/2020 at 11:45 a.m. with RN JJ; 11/2/2020: 6:42 a.m. with LPN UU, 6:45 a.m. with CNA WWW, 6:48 a.m. with CNA BBBB, 6:52 a.m. with CNA OOO, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; 11/4/2020: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; 11/5/2020: 1:50 p.m. with CNA CCCC and 2:53 p.m. with CNA EEEE; 11/6/2020 at 11:01 a.m. with RN KK; and 11/10/2020 at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 7. Review of the weekly Clinical Skin System Audit Tool starting 10/19/2020 revealed skin assessments were completed daily per the skin assessment schedule. The Physician, RP, and Wound nurse were notified of identified skin issues. The audits were reviewed weekly and signed by the DON, ADON, Wound Nurse, RN Supervisor, and the MDS Coordinator. During an interview on 11/2/2020 at 2:33 p.m., the DON stated that the Charge Nurses are completing the weekly skin checks on the residents and if the skin check reveals a new skin concern, it flags for a Braden Scale to be completed. If the Braden Scale reflects a resident to be at HIGH risk for pressure ulcer, then the treatment nurse will re-assess the resident and if the assessment is accurate, treatment orders will be implemented, and care plan will be updated. The Physician and the responsible party will be notified as well as making sure orders are followed through. 8. Review of the Care Plan Item/Task Listing Report revealed a list of residents in the facility and the residents bath schedule. The Documentation Survey Report revealed a section to document skin observation and to note if it is a new skin condition. R#15, R#29, R#31, R#37, R#38, and R#39 had bath schedules and findings documented on the Documentation Survey Report dated 10/21/2020. 9. The EMR Audit Report and Clinical Audit tool revealed daily review starting 10/19/2020 of the bath schedules and skin notations. Interview on 11/6/2020 at 3:00 p.m. with the DON revealed that the EMR Report is generated daily to identify residents that have missed a scheduled bath. The DON stated she would further investigate any residents that missed a scheduled bath. The Clinical System Audit Tool is generated based on Physician Treatment Orders from the previous day. 10. Review of facility Wound Management Tracking Tool dated 10/23/2020 revealed 11 residents with pressure ulcers or other significant wounds are being followed by Wound Physician. Ten of the 11 residents were seen by the Wound Physician on 10/29/2020. The 11th resident was in the hospital on the day of the Wound Physician visit. Wound Management Tracking Tool dated 10/16/2020 revealed 12 residents with pressure ulcers or other significant wounds are being followed by Wound Physician. 10 of the 12 residents were seen by the Wound Physician on 10/22/2020. One resident was in hospital and the other resident's wound was resolved on 10/15/2020. Review of Wound Tracking Tool dated 10/9/2020 revealed 10 residents with pressure ulcers or other significant wounds are being followed by Wound Physician. An interview on 11/5/2020 at 10:58 a.m. with Physician EE revealed she started at the facility on 10/15/2020 and will come weekly on Thursday. She stated weekly high-risk meeting are conducted at the end of rounds on Thursday. The wound nurse, DON, ADON, the SWC (Skilled Wound Care) Business Development Nurse (via phone) and herself are in attendance. The team discuss residents that currently have wounds and any resident that has the potential for wounds is discussed as a group. Interview on 11/5/2020 at 4:29 p.m. with LPN NN revealed that she makes rounds with the Wound Physician each week and visits all the residents with wounds or other skin conditions. She stated that she keeps track of residents with wounds for the Wound Physician to see each week. 11. Review of the QAPI Meeting Minutes dated 10/23/2020 revealed the RDO, RDCS, ADON, Admission Director, Activities Director, Environmental Service Manage, Maintenance, Marketing Director, MDS Coordinators, and the Dietary Manager were in attendance. Specific Subject Matter Topics: IJ Issuance and Abatement Plan, skin audits, wound log, reviewed the purpose of the weekly at-risk meeting, concerns identified, communication, policy review, QAPI schedule, and staff education. Review of the QAPI Meeting Minutes dated 10/30/2020 signed by the Medical Director, Administrator, DON, Admission Director, Wound Nurse, ADON, Activities Director, Environmental Service Manager, Maintenance, Marketing Director, RN Supervisors, MDS Coordinators, and the Dietary Manager. Specific Subject Matter Topics: audits, skin integrity, baths, staffing, new PIP (process improvement plan). Review of a typed statement on the facility's letterhead revealed daily and weekly skin audits (Clinical Skin System Audit Tool) results were reviewed by the Administrator with the Physician and QAPI committee attendees on 10/17/2020, 10/23/2020 and 10/30/2020. Audit results will continue to be reviewed at each subsequent QAPI meeting. Reviewed by phone with Medical Director on 10/23/2020; all other communication done in person. Signed by the Administrator. Interview on 11/4/2020 at 2:27 p.m. with the Administrator revealed she reviewed each of the facility audit reports and reports to the Medical Director and Interdisciplinary Team during QAPI meetings.

Based on observation, record review, review of the facility policy titled Skin Integrity Management and staff interviews, the facility failed to follow Physician Orders for a wound consult and doppler study; and failed to conduct weekly skin assessments for one resident (R) (#1). In addition, the facility failed to apply a topical skin cream, as ordered, for one resident (R#5) of 36 sampled residents. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:45 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: R#1 was readmitted to the facility on [DATE]. On [DATE], staff identified the first three digits of the left foot to be black and discolored. The Physician was not notified. On [DATE], staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On [DATE], staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Findings include: Review of the policy titled Skin Integrity Management revision date [DATE] indicated - Policy: The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Purpose: To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Practice Standards:3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 3.1 Perform skin inspection on admission/re-admission and weekly. 1. A review of the Admission Record (face sheet) for R#1 revealed she was admitted to the facility on [DATE] and a readmission on [DATE] [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. Section E documented no behavior exhibited. Section M revealed the resident is at risk for developing pressure ulcer and had no pressure ulcers, zero venous, or arterial ulcers. Pressure ulcer triggered as an area of concern on the Care Area Assessment Summary (CAAS). A review of the care plan dated [DATE], revealed that R#1 is at risk for pressure ulcer related to her frequently incontinence of bowel and bladder and her decreased mobility. Intervention to be implemented included weekly skin assessments. Observe skin condition with ADL care daily and report abnormalities. Review of the Electronic Medical Record (EMR) for R#1 revealed a Physician Order dated [DATE] for weekly skin assessment every night shift on Mondays for wound prevention. Further review revealed a Physician Order dated [DATE] for Arterial Doppler study one time only for left lower extremity schedule ASAP (as soon as possible) and [MEDICATION NAME] day shift for left foot, paint left foot daily. The Skin Check in the EMR for R#1 revealed the last skin check was completed on [DATE] and revealed no identified skin issues. A review of the EMR for R#1 Skin Check dated [DATE] revealed: The left foot, the first three digits of foot are black and discolored. Patient complained of pain and discomfort in foot. Patient given something for pain. Another nurse was called into to look. No documented evidence that the nurses notified the Physician and family of the resident's change in condition. A review of Nurse Practitioner Encounter dated [DATE] revealed: resident was seen in her/his room today while in bed. She is seen today for the management and treatment of [REDACTED]. Health Status: The patient was seen and examined. General: No acute distress. Integumentary: Warm, Clean, Dry. Mental status/ Cognition: Alert, Oriented X3 (person place and time). A review of the EMR Wound/Skin Note dated [DATE] revealed: Asked to observe left foot (the writer). First three toes of left foot, with necrotic, devitalized tissue, with small open areas. A telephone order received from the NP (Nurse Practitioner) for [MEDICATION NAME] daily, have the Wound Physician see the resident and for Arterial Doppler study ASAP (as soon as possible). The telephone order was transposed to the EMR although there was no evidence of follow through for these orders. A review of the EMR Nurse's Note dated [DATE] revealed: Wound to resident's left foot noted to have deteriorated. Director of Nursing (DON) and NP contacted. Nurse Practitioner given assessment and new orders to send out for evaluation and treatment of [REDACTED]. Resident transported to the local Hospital. A review of the hospital emergency room (ER) records dated [DATE] revealed: Chief Complaint patient presents with maggots to left toes. A review of the Hospital Operative Note dated [DATE] revealed: Findings: preoperative diagnosis-gangrenous left foot infested with maggots, with procedure left [MEDICAL CONDITION] (LBKA). Interview on [DATE] at 10:30 a.m. with Physician BB revealed on Saturday [DATE] R#1 was brought from the facility into the emergency room for a complaint of infected toes on the left foot. Physician BB reported upon examination of R#1 her left foot was embodied with maggots. He stated he did not count the maggots, but it was a lot. Physician BB stated on Sunday [DATE] R#1 left leg had to be amputated. He also, revealed that R#1 leg was sent to the pathologist. Review of the Hospital Pathologist Report dated [DATE] revealed a Gross Description: The distal part of the foot is necrotic and is black in color. The necrotic area involves all the toes and measures 6 x 8 centimeters. Live maggots are noted in the ulcerated necrotic areas, involving all toes. These maggots measure 1.2 in length each. Interview on [DATE] at 11:15 a.m. with NP GG revealed she received a call and pictures on [DATE] informing her of the condition of R#1's left foot. She stated she was informed by the caller that R#1 toes on left foot were dark. NP GG revealed the last time she seen R#1 was on [DATE] and on [DATE] the day before she was sent out to the hospital. NP GG stated she did not assess the resident's feet on [DATE] and she did not assess the left foot on [DATE]. NP GG stated she does not look at any resident's feet. During a phone interview on [DATE] at 2:01p.m., LPN OO stated R#1 had toes on the left foot that were black and necrotic with some open areas. She stated she notified the NP and was given orders to schedule R#1 to see the facilities wound Physician on [DATE], [MEDICATION NAME] daily, and arterial doppler study. 2. A review of the Admission Record (face sheet) for R#5 revealed she was admitted to the facility [DATE] with multiple [DIAGNOSES REDACTED]. The Annual MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Section M revealed the resident is at risk for developing pressure ulcer. Coded no pressure ulcers, zero venous and arterial ulcers. Pressure ulcer triggered as an area of concern on the CAAS. An observation and interview were conducted on [DATE] at 12:00 p.m. of R#5 right and left foot with LPN NN. The resident revealed two days ago, something was biting her in between toe. The resident revealed she scratched the area, and she broke the skin. The resident revealed she reported this to LPN FFF this past weekend, and the nurse told her she would assess the area but never returned to the room. Observation of the right and left foot revealed dry, flaky skin and a dark color in between toes. A review of the Podiatry Consultant Report dated [DATE] revealed: Reason for visit right great toe pain. Ingrown nail trimmed back with immediate relief. Follow-up sooner if symptoms worsen. [MEDICATION NAME] topical cream apply to bottom feet, top of feet and interspaces. A review of the Physician Order dated [DATE] revealed [MEDICATION NAME] topical cream apply to bottom feet, top of feet and interspaces twice a day. Interview on [DATE] at 1:15 p.m. with Doctor of Podiatry Medicine (DPM) CC revealed that R#5 has a right great toe in grown nail and fungus in between the toes (bad). DPM CC revealed the toenail was trimmed and needs to be monitored and have follow up sooner than 61 days. DPM CC stated she ordered [MEDICATION NAME] topical cream to be applied to both feet top, bottom, and interspaces. Very important that it is applied twice a day. An interview on [DATE] at 9:35 a.m. with R#5 stated her feet feels a lot better. Resident stated she has never had any cream on both feet. The resident stated the doctor talk about ordering cream for my feet, but no one has put any cream on my feet. Although the EMR MAR indicated [REDACTED]. Interview on [DATE] at 11:00 a.m. with the DON revealed she has been employed at the facility since [DATE]. She stated that her expectation for all the staff is to provide the residents care according to Physician orders. She stated she would expect them to ask questions and seek clarification of things they do not know. The facility implemented the following actions to remove the IJ: 1. RI (Resident) #1 no longer resides at the facility 2. On [DATE] the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Resident Rights and Skin Integrity Policy. No policy changes or recommendations were made as a result of this review. 3. On [DATE] a Root Cause Analysis (RCA) of the skin integrity system breakdown was completed by Regional Director of Operation, Regional Director of Clinical Services, Medical Director, Administrator and Director of Nursing. Documentation of analysis was put on the RCA Tool and will be included in the next Quality Assurance Performance Improvement (QAPI) meeting. 4. On [DATE] the Director of Clinical Services reviewed residents' skin check and bath schedules to identify areas of concern. Findings of the review will be documented on the Skin Audit Tool. 5. A second set of whole house (99 of 102 residents with 3 refusals) skin assessments was completed on [DATE] -17 by the center charge nurses to identify any additional skin concerns. Any new concerns identified will be documented on the body audit sheet, reported to the MD and any orders obtained will be implemented. Plan of care will be updated, and responsible parties will be notified 6. On [DATE] - 17, 2020 the Director of Clinical Services reviewed all body audit sheets for change in condition, and to validate MD and RP notification. Review was documented on the Skin Audit Tool and shared with the Administrator and Director of Nursing. 7. Nursing employees (RNs 5 of 6 -83%; LPNs 22 of 25 -88%; CNAs 35 of 39 -90%/ Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%) will be educated by Administrator on the importance of completing and documenting scheduled weekly skin checks and bath schedules by [DATE] - 19, 2020. Teleconference/phone in-servicing was provided to RN 1, LPNs 3, CNAs 3 on [DATE]. Employees on leave of absence FMLA- (3 LPNs and 3 CNAs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 8. The Regional Director of Clinical Services educated licensed nurses (RNs 3 of 6; LPNs 19 of 25/Agency: RN 0 of 1; LPNs 4 of 8; Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%) on how to properly conduct a complete head to toe assessment in order to capture any skin alterations by 10/l,[DATE]. Teleconference/phone in-servicing was provided to RN 1, LPNs 3 on [DATE]. Employees on leave of absence FMLA- (3 LPNs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 9. Residents identified as high risk for developing pressure ulcers on their Braden Scale assessment will have a weekly skin re-assessment by the Nurse Managers to make sure all impaired skin has been assessed and captured, with MD notification and orders implemented per Physician orders. The Body Audit Tool will be utilized as the assessment tool. 10. The Director of Nursing and Nurse Managers will review skin checks from the previous day during daily clinical meetings and will verify Physician notification, orders implementation per Physician Orders, updated plan of care and family notification. Results of this review will be documented on utilizing the Clinical Meeting Skin System Audit Tool. 11. Residents with pressure ulcers and significant wounds will be assessed and followed by the visiting wound Physician and his orders will be implemented by the center. Any changes made by the Wound Physician will be communicated to the resident's family and documented in the progress note in ELECTRONIC MEDICAL RECORD. 12. The center will conduct a weekly skin at risk meeting by the clinical interdisciplinary team (consisting of ADON (Assistant Director of Nursing), MDS, Unit Managers, Wound Nurse, RN Supervisors) to ensure the plan of care of residents with wounds and pressure ulcers are being followed. 13. Center hired an experienced wound nurse on [DATE] to help champion the skin integrity system and improve skin outcomes. Another new hire RN wound nurse to start [DATE] to provide additional oversight to the Skin Integrity Management Program. 14. On [DATE] center contracted with a new Wound Physician group to come to the center on an on-going basis to address residents with wounds and significant skin conditions. Wound Physician will assess, evaluate, treat all residents identified with wounds based on the wound nurse weekly wound report, any new reported wounds or guidance/referral of the wound nurse. 15. On [DATE] as a result of the RCA, the Medical Director, Regional Director of Operations, Regional Director of Clinical Services, Administrator and Director of Nursing changed the current process of paper skin checks to electronic. All weekly skin checks were entered into ELECTRONIC MEDICAL RECORD as a Physician order and scheduled on the TAR for completion and signature by charge nurses. This will allow for the schedule and process to be easily monitored by oversight supervisors such as the Regional Director of Clinical Operations by running reports. 16. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the Medical Director and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the facility census list revealed billing stopped for R#1 on [DATE] which was her discharge date . Interview with the Family of R#1 on [DATE] at 9:30 a.m. revealed that the resident was discharged from the hospital and currently resides at a different nursing home. 2. Review of facility Internal Policy Review Form revealed Resident Rights policy was reviewed on [DATE] with no recommended changes needed. The Skin Integrity Management policy was also reviewed on [DATE] with no recommended changes needed. During an interview on [DATE] at 1:15 p.m. the Medical Director stated the facility has a Resident Rights and Skin Integrity Policy in place that does not require any changes. 3. A Root Cause Analysis (RCA) was completed on [DATE] and revealed the Administrator, Medical Director, DON, Director of Operations and Regional Director of Clinical Services completed the RCA. The RCA revealed that a skin check was completed for R#1 on [DATE] and agency nurse failed to notify the Physician, family or facility leadership of discovery of discolored toes and no plan of care initiated. Review of Corrective Actions are ongoing. 4. Review of letter dated [DATE] signed by the Regional Director of Clinical Services revealed that resident skin assessments were not being completed in a timely manner. A recommendation was made to adjust the skin assessment schedule to include adding skin assessments to the Medication Administration Records (MAR) and a skin assessment flag will appear on the EMR dashboard to alert the nurse as a reminder. The skin assessments will be audited daily by the DON or her designee. Review of Skin Audit Tool Summary dated [DATE], signed by the Regional Director of Clinical Services revealed that a new bath schedule was recommended to include baths three times per week, either Monday/Wednesday/Friday or Tuesday/Thursday/Saturday, scheduled per resident preference, reviewed daily in clinical meetings and documenting refusals and reporting to nurse. Interview on [DATE] at 5:15 p.m. with the Regional Director of Clinical Services revealed that she reviewed the skin assessment schedule and recognized that residents were not receiving weekly skin assessments. A new schedule was created, and the weekly skin assessment is now added to the MAR indicated [REDACTED]. The DON will review the skin checks daily. During further interview, she stated that the bath schedule was reviewed, and she made recommendations. She stated that she held meetings with the staff consisting of 1:1's, group meetings, huddles, head to toe/skin check meetings and phone education to staff members unable to attend an in-person meeting. She stated that she discussed with them switching to three day per week bath schedule, to be divided between the three shifts, based on resident preference. She stated that they were educated on documenting the baths in the kiosk and reporting to the Charge Nurses. She educated the Licensed Nursing staff on a new skin audit schedule that will be implemented and will coincide with the EMR, to show a skin check due on a weekly basis, on a specific day, according to the paper schedule. Interview on [DATE] at 5:55 p.m. with the DON revealed that she currently is reviewing all the daily skin checks. If the nurses have identified any concerns, she checks to make sure the nurses have followed through with new orders and updating care plans, if indicated. 5. Review of the daily census sheet dated [DATE] revealed a total census of 101. Review of the IMG_0189.jpeg (facility using to document skin assessments) revealed three residents refused the skin assessment. Review of the total number of IMG_0189.jpeg sheets completed was 102 including the three residents that refused. SBAR (Situation, Background, Appearance, Review/Notify) were completed for all identified skin concerns with family and Physician notification documented. There were no further concerns related to abuse or neglect. During an interview on [DATE] at 10:35 a.m., the Regional Director of Clinical Services (RDCS) stated the facility document titled IMG_0189.jpeg are Body Audits. The change in condition (CIC) and SBAR are the same assessment tools. The task started on [DATE] and was completed on [DATE]. She stated the LPN's and MDS Coordinators completed 99 resident body audits and three residents refused the skin assessment. She stated the Body Audits were compared with the previous skin sweep ([DATE] and [DATE]) and the last two skin checks in the electronic health record. They reviewed the documentation for progress notes, notification of the Physician and Responsible Party, orders that were carried out, completion of the CIC/SBAR and an update of the care plan. 6. Review the of the statement on the facility letterhead dated [DATE] signed by the RDCS revealed the Body Audits from the house skin sweep were reviewed. The RDSC noted six residents with new areas. The statement further stated that the Physician and RP were notified. The findings were reported to the Administrator and DON. Finding were shared during the AD HOC Committee meeting. An interview was conducted on [DATE] at 11:19 a.m. with the RDCS. She confirmed review of all body audit sheets for change in condition, and to validate Physician and RP notification. The information was communicated to the Administrator and the DON. 7. Review of facility in-service record dated [DATE] through [DATE] revealed 7 RN's, 31 LPN's and 52 CNA's received education on the importance of completing and documenting weekly skin assessments and body audits during scheduled baths. 8. Review of facility in-service record dated [DATE] revealed 7 RN's and 32 LPN's received education how to properly conduct a complete head to toe assessment to capture any skin alterations. Also verified the above in-services via the following staff interviews on [DATE] at 11:45 a.m. with RN JJ; [DATE]: 6:42 a.m. with LPN UU, 6:45 a.m. with CNA WWW, 6:48 a.m. with CNA BBBB, 6:52 a.m. with CNA OOO, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; [DATE]: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; [DATE]: 1:50 p.m. with CNA CCCC and 2:53 p.m. with CNA EEEE; [DATE] at 11:01 a.m. with RN KK; and [DATE] at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 9. Review of the facility documentation for Braden Scale completed from [DATE] through [DATE] revealed there was a total of five residents who were identified by facility staff to be at high risk for developing pressure ulcers on their Braden Scale. R#15, R#29, R#31, R#37, R#38, and R#39 had skin assessments completed as scheduled and reported timely to the family and Physician. No concerns were identified. R#36 had a skin assessment scheduled for [DATE]. During observation and interview on [DATE] at 11:30 a.m., LPN MMM completed the skin assessment for R#36 without concern. The schedule was posted at the nurse's station and in the User Defined Assessment (UDA) of the electronic health record. R#25 had a skin assessment scheduled for [DATE]. During observation and interview on [DATE] at 10:10 a.m., LPN VV completed the skin assessment for R#25 without concern. The schedule was posted at the nurse's station and in the User Defined Assessment (UDA) of the electronic health record. 10. During an interview on [DATE] at 2:33 p.m., the DON stated that the Charge Nurses are completing the weekly skin checks on the residents and if the skin check reveals a new skin concern, it flags for a Braden Scale to be completed. If the Braden Scale reflects a resident to be at HIGH risk for pressure ulcer, then the treatment nurse will re-assess the resident and if the assessment is accurate, treatment orders will be implemented, and care plan will be updated. The Physician and the Responsible Party will be notified as well as making sure orders are followed through. 11. A review of the Weekly Wound Management Tracking Tool dated [DATE], [DATE], and [DATE] revealed the Wound Care Team was in the facility and saw 12 of 12 residents on the list. Review of the Progress Notes for the residents with wounds revealed no issues noted. 12. A review of the weekly At-Risk Meeting sign in sheet dated [DATE] signed by the DON, ADON, Wound Nurse, and RN supervisor. The minutes revealed the facility discussed the residents on the wound management tracking tool, the residents identified in the skin sweep on [DATE] and [DATE], and the updated skin check schedule. The interdisciplinary team (IDT) also discussed Braden Scores, notification, and the EMR communication board. A review of the weekly At-Risk Meeting sign in sheet dated [DATE] signed by the DON, ADON, Wound Nurse, and Wound Team. The minutes revealed a discussion of five residents that are currently being treated for [REDACTED]. An interview on [DATE] at 10:58 a.m. with Physician EE revealed she started at the facility on [DATE] and will come weekly on Thursday. She stated weekly high-risk meeting are conducted at the end of rounds on Thursday. The wound nurse, DON, ADON, the SWC (Skilled Wound Care) Business Development Nurse (via phone) and herself are in attendance. The team discuss residents that currently have wounds and any resident that has the potential for wounds is discussed as a group. 13. Review of the job description revealed employee, LPN NN, accepted responsibilities of the position on [DATE]. On [DATE], a second Wound Nurse, RN KK, began employment to provide additional oversight to the Skin Integrity Management Program. Interview on [DATE] at 4:29 p.m. with LPN NN revealed that she was informed about the wound care situation at the facility when she was hired. She stated that she accepted the responsibilities of her job description and that she has gotten good support from the administrative staff. She stated that she has plenty of supplies to take care of the residents wound care needs. Interview on [DATE] at 11:01 a.m. with RN KK revealed that she has been in orientation since her hire date of [DATE]. She stated that she will be working day shift and will share the wound care responsibilities with LPN NN. She stated that she was informed about the situation with the wound care system when she was hired. She further stated that she and LPN NN have been working to ensure that wound care is covered seven days per week. 14. Review of a contract with the Wound Physician Group and the facility revealed that the Wound Physician Group agrees to provide Physician related wound, ostomy, and skin care services to all patients within the facility for whom wound, ostomy and skin care consultation has been requested. Interview on [DATE] at 10:48 a.m. with Physician EE revealed that she began seeing residents in the facility on [DATE] and will be making her weekly visits on Thursdays. 15. A Root Cause Analysis (RCA) was completed on [DATE] and revealed the Administrator, Medical Director, DON, Director of Operations and Regional Director of Clinical Services completed the RCA. The RCA resulted in changing the current process of paper skin checks to electronic. All skin checks were entered into the electronic health record as a Physician order and was scheduled on the TAR. A new weekly skin assessment schedule was created which divided the skin assessments over two 12-hour shifts. Interview on [DATE] at 10:30 a.m. with the Administrator revealed that the determination of the Root Cause Analysis (RCA) was made by looking at everything leading up to the situation with R#1. She stated that they looked at skin assessments and realized they were not being done weekly, that Physician Orders were not being followed through, and that staff communication was not being done between staff members. She stated that it's like they were keeping the information to themselves. During further interview, she stated the Unit Managers will eventually be responsible for making sure the skin checks are being done, but for now, the DON is checking them. 16. Review of the QAPI Meeting Minutes dated [DATE] revealed the RDO, RDCS, ADON, Admission Director, Activities Director, Environmental Service Manage, Maintenance, Marketing Director, MDS Coordinators, and the Dietary Manager were in attendance. Specific Subject Matter Topics: IJ Issuance and Abatement Plan, skin audits, wound log, reviewed the purpose of the weekly at-risk meeting, concerns identified, communication, policy review, QAPI schedule, and staff education. Review of the QAPI Meeting Minutes dated [DATE] signed by the Medical Director, Administrator, DON, Admission Director, Wound Nurse, ADON, Activities Director, Environmental Service Manager, Maintenance, Marketing Director, RN Supervisors, MDS Coordinators, and the Dietary Manager. Specific Subject Matter Topics: audits, skin integrity, baths, staffing, new PIP (process improvement plan). Review of a typed statement on the facility's letterhead revealed daily and weekly skin audits (Clinical Skin System Audit Tool) results were reviewed by the Administrator with Physician and QAPI committee attendees on [DATE], [DATE] and [DATE]. Audit results will continue to be reviewed at each subsequent QAPI meeting. Reviewed by phone with Medical Director on [DATE]; all other communication done in person. Signed by the Administrator. Interview on [DATE] at 2:27 p.m. with the Administrator revealed she reviewed each of the facility audit reports and reports to the Medical Director and Interdisciplinary Team during QAPI meetings.

Based on observation, record review, review of the facility policy titled GA Abuse Prohibition- State of Georgia, resident and staff interviews, the facility failed to protect one resident (R) (#1) from neglect by not notifying the Physician and appropriately treating a left foot wound which became infested with maggots of 36 sampled residents. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:45 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: R#1 was readmitted to the facility on [DATE]. On [DATE], staff identified the first three digits of the left foot to be black and discolored. The Physician was not notified. On [DATE], staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On [DATE], staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Findings include: Review of the policy titled GA Abuse Prohibition- State of Georgia effective date ,[DATE] indicated Policy will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: Screening of potential hires, Training of employees, Prevention, Identification, Investigation, Protection, and Reporting/Response. Definitions: Neglect is defined as the failure to provide goods services necessary to avoid physical harm, mental anguish, or mental illness. Purpose to ensure that the center staff are doing all that is within control to prevent occurrences of abuse, neglect, mistreatment, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all parties. A review of the Admission Record (face sheet) for R#1 revealed she was admitted to the facility on [DATE] and a readmission on [DATE] [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 3 out of 15 which indicated severe cognitive impairment. Section E no behavior exhibited. Section G extensive assistance with bed mobility, transfer, personal hygiene dressing, and toilet use. Limited assistance with eating. Section M revealed the resident high risk for pressure ulcer but had no pressure ulcers, zero venous, or arterial ulcers in this assessment period. A review of R#1 Electronic Medical Record (EMR) revealed a Physician Order dated [DATE] for weekly skin assessment every night shift on Mondays for wound prevention. There was no documented evidence that the facility was conducting a weekly skin check on R#1 as ordered on [DATE] by the Physician and per the facility's policy. The Electronic Medical Record (EMR), Skin Check dated [DATE] revealed: The left foot, the first three digits of foot are black and discolored. Patient complained of pain and discomfort in foot. Patient given something for pain. Another nurse was called into to look. No documented evidence that the nurses notified the Physician and family of the resident's change in condition. A review of Nurse Practitioner Encounter dated [DATE] revealed: resident was seen in her/his room today while in bed. She is seen today for the management and treatment of [REDACTED]. General: No acute distress, well developed. Alert in no distress. Eye: Pupils are equal, round, and reactive to light, extraocular movements are intact. Head Eyes Ears Neck Throat (HENT) {sic}: Normocephalic, atraumatic, without obvious abnormality; Neck: Supple, Non-tender. Trachea midline Respiratory: Lungs clear to auscultation; Respirations are non-labored. Effort normal Cardiovascular: Normal S1, S2 (first and second heart sound), Normal rate, Regular rhythm. Intact distal pulses. Gastrointestinal: Soft, Non-tender. Normal active Bowel sounds + (positive)X4 (all four quadrants). Integumentary: Warm, Clean, Dry. Mental status/ Cognition: Alert, Oriented X3 (person place and time). A review of the EMR Wound/Skin Note dated [DATE] revealed: Asked to observe left foot (the writer). First three toes of left foot, with necrotic, devitalized tissue, with small open areas. A telephone order received for the NP for [MEDICATION NAME] daily, have the Wound Physician see the resident and for Arterial Doppler study ASAP (as soon as possible). The telephone order was transposed to the EMR although there was no evidence of follow through for these orders. No evidence that the family was notified. A review of the EMR Nurse's Note dated [DATE] revealed: Wound to resident's left foot noted to have deteriorated. Director of Nursing (DON) and NP contacted. Nurse Practitioner given assessment and new orders to send out for evaluation and treatment of [REDACTED]. Resident transported to the local Hospital. A review of the hospital emergency room (ER) records dated [DATE] revealed: Chief Complaint patient presents with maggots to left toes. A review of the Hospital Operative Note dated [DATE] revealed: Findings: preoperative diagnosis-gangrenous left foot infested with maggots, with procedure left [MEDICAL CONDITION] (LBKA). A review of the Hospital Pathology Report final report dated [DATE] revealed [MEDICAL CONDITION]. The distal part of the foot is necrotic and is black in color. Live maggots are noted in the ulcerated necrotic areas, involving all the toes. These maggots measured 1.2 inches in length each. An interview was conducted on [DATE] at 10:30 a.m. with Physician BB. He stated on Saturday [DATE] a resident from the facility was brought into the emergency room for a complaint of infected toes on the left foot. Physician BB reported upon examination of R#1, her left foot was embodied with maggots. He did not count the maggots, but it was a lot. Physician BB stated on Sunday, [DATE], R#1's left leg had to be amputated. He also revealed that R#1's leg was sent to the pathologist. Physician BB provided the surveyor with a video of R#1's foot with the maggot infestation. An interview on [DATE] at 11:15 a.m. with NP GG revealed she received a call and pictures on [DATE] informing her of the condition of R#1's left foot. She stated she was informed by the caller that the toes on left foot were dark. NP GG revealed the last time she saw R#1 was on [DATE] and again on [DATE] the day before she was sent out to the hospital. NP GG stated she did not assess the resident's feet on [DATE] and she did not assess the left foot on [DATE]. NP GG stated she does not look at any resident's feet. An interview on [DATE] at 12:30 p.m. with Licensed Practical Nurse (LPN) JJJ revealed that on Saturday [DATE] at approximately 11:20 a.m. two Certified Nursing Assistants (CNA) asked her to come and assess R#1's left foot. LPN JJJ revealed when she arrived in the room to assess the left foot, she noted all the resident toes on the left foot were black and the foot was infested with maggots. She stated during the assessment, R#1 exhibited signs of pain and discomfort. The resident pulled her left foot away when touched and made noises as if she were in pain. She stated the DON and NP were notified immediately and the DON was provided with a picture. The NP gave orders to send to R#1 to the ER. She wrote a statement and instructed the two CNA's to also write a statement. She stated the statements were provided to the DON. LPN JJJ provided the surveyor with a picture of R#1 foot. An interview on [DATE] at 12:45 p.m. with R#11 (R#1's roommate with BIMS of 13, indicating cognition intact) revealed that R#1 would complain all the time that her feet were hurting. R#11 stated when her roommate would complain to her she would put her light on and let the nurse know. She stated she does not remember if the staff would look at the resident's feet when she complained but the staff would bring something in for the pain. R#11 stated on occasion there would be flies in the room. An interview was conducted on [DATE] at 1:00 p.m. with CNA ZZZ who stated on [DATE] between 10:30 a.m.-11:30 a.m. she went in R#1 room to give her a bed bath for the day. The resident had complaints of discomfort of the left foot. CNA ZZZ stated when she looked at R#1 left foot it was leaking maggots. She stated there were so many maggots in the residents left foot and on the bedding. She asked her coworker to have the nurse to come into the room. At that point she attempted to clean the maggots out with the washcloth, and she used two clothes that were full of maggots. CNA ZZZ stated around a thousand of maggots were inside of R#1's foot and she could hear the maggots making a scratching sound. During an interview on [DATE] at 1:35 p.m., LPN TT stated that on [DATE] a CNA asked her to go and assess R#1 because the patient was itching. She stated R#1 told her that she was not itching, her left foot was hurting. She stated upon assessing the resident's left foot the third toe looked like a raisin (wrinkled) and the toe looked like it was going to fall off and the second toe on the left foot was purple. Stated she asked another nurse to come asses the residents left foot. LPN TT stated she did not notify the Physician, family, or DON. LPN TT stated she did not know where to look for the family or the Physician's number. She stated she did have the DON's number but failed to call the DON. She stated, it was poor judgement not notifying the Physician and the family. LPN TT stated she has never received an orientation on the facility's policy and procedures. LPN TT stated she never completed a skin check in the EMR on R#1. An interview on [DATE] at 2:01 p.m. with LPN OO revealed that on Wednesday [DATE], one of the CNA's approached her and asked that she assess R#1's left foot. She stated the toes on the left foot were black and necrotic with several open areas on the toes. LPN OO sent a picture to the NP of R#1's left foot. She stated she also called the NP and was given orders to schedule R#1 to see the Wound Physician on [DATE], [MEDICATION NAME] daily, and arterial doppler study. LPN OO provided the surveyor with the picture she sent the NP. Review of the picture taken on [DATE] of R#1's foot revealed the first three toes were black. Two maggots were visible on the top of R#1's foot near the third toe. An interview on [DATE] at 12:30 p.m. with the Medical Director (MD) revealed the NP made him aware of R#1's left foot on [DATE]. The MD stated the NP did not provide him with the picture. He stated he instructed her to order a doppler and have the resident seen by the Wound Physician the next day. The MD stated if he had seen the picture of the resident's foot, he would have ordered to send her to the hospital. An interview on [DATE] at 1:54 p.m. with the DON revealed she did not investigate why or how R#1 had necrotic toes that were infested with maggots. She stated the staff neglected to complete a weekly skin check and did not follow Physician/NP orders. The DON she stated her expectation is that the resident's baths and skin report are completed by the CNA's as assigned, and the residents weekly skin check should be completed by the licensed staff as assigned. An interview on [DATE] at 8:50 a.m. with Wound Physician AA revealed he makes rounds at the facility every Thursday. Wound Physician AA stated he was in the facility on [DATE] and he was not asked to assess R#1's left foot. He further stated he would had seen the resident if had been notified. An interview was conducted on [DATE] at 3:25 p.m. with the Administrator who stated she became aware of R#1's left foot on [DATE] after receiving a call from the DON. The Administrator stated she did not consider when R#1 was found with necrotic toes that were infested with maggots to be abuse or neglect. During an interview on [DATE] at 2:45 p.m., the Administrator stated the facility has approximately 126 staff. She revealed approximately 95% of the staff have been educated on Abuse and Neglect. The Administrator stated the staff was educated on the Abuse and neglect policy and who the abuse coordinator is and the role of the abuse coordinator. She stated the staff was educated to report and notify her immediately anything that made them (staff) feel uncomfortable. She stated anytime she receives an allegation of abuse or neglect she will ask the person that makes the initial report to complete a statement. The staff involved would be suspended pending the investigation. The allegation of abuse or neglect is reported to the State Survey Agency immediately within 2 hours. The family is notified of the abuse or neglect when it occurs and notified of the outcome of the investigation within five business days. Abuse and Neglect in-service are conducted once a quarter. The Administrator stated the outcome for R#1 would have been different if the facility had a unit manager in place, weekly skin check where done consistently, and baths being completed consistently. The Administrator stated after [DATE] the facility had no unit manager, no leadership/management to make sure that the staff was consistent with following process. The facility implemented the following actions to remove the IJ: 1. Licensed Nurse (s) #1 was educated by Administrator on center Notification of Change, following Physician Orders and Abuse and Neglect Prohibition policy on [DATE]. On [DATE] agency employee will no longer be utilized by this center and will be reported to the Georgia Board of Nursing. 2. Licensed Nurse (s) #2 was educated by Administrator on center Notification of Change, following Physician Orders and Abuse and Neglect Prohibition policy on [DATE]. 3. Wound Nurse no longer employed at this center 4. Medical Director educated NP on patient assessments and Abuse and Neglect Prohibition Policy on [DATE]. On [DATE] NP will no longer be utilized by this center and will be reported to the Georgia Board of Nursing. 5. On [DATE] the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Abuse and Neglect. No policy changes or recommendations were made as a result of this review. 6. Administrator interviewed 5 residents receiving wound care deemed as interviewable regarding skin assessments and wound care on [DATE]. Interview was documented on the Resident Wound Interview Tool. Identified concerns were addressed as needed and plan of care updated. 7. A second set of whole house (99 of 102 residents with 3 refusals) skin assessments was completed on [DATE] -17, 2020 by the center charge nurses to identify any additional skin concerns. Any new concerns identified will be documented on the body audit sheet, reported to the MD and any orders obtained will be implemented. Plan of care will be updated, and responsible parties will be notified. No new concerns of abuse or neglect were identified. 8. On [DATE] -17, 2020 the Director of Clinical Services reviewed all body audit sheets for change in condition, and to validate MD and RP notification. Review was documented on the Skin Audit Tool and shared with the Administrator and Director of Nursing. 9. Administrator reviewed the grievance log in the last 60 days relating to skin concerns to identify possible allegations of Abuse and Neglect and ensure appropriate actions were implemented as necessary. Recommendations were reviewed in AD-HOC Performance Improvement meeting [DATE]. 10. Regional Vice President of Operations re-educated the Administrator and Director of Nursing on the Abuse and Neglect Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations on [DATE]. 11. Administrator re-educated Nursing employees (RNs 5 of 6 -83%; LPNs 22 of 25 -88%; CNAs 35 of 39 -90%/Agency: LPNs 6 of 7- 86%; CNAs 7 of 8- 88%) on the Abuse and Neglect policy and procedure and notification requirements of the Physician, NP and RP by [DATE]. Teleconference/phone in-servicing was provided to RN 1, LPNs 3, CNAs 3 on [DATE]. Employees on leave of absence FMLA- (3 LPNs and 3 CNAs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 12. The Director of Nursing will review weekly skin check schedule for completion during daily clinical meeting to validate completion and notification of change. Results of this review will be documented on the Clinical Skin System Audit Tool. 13. Charge nurses will complete weekly skin checks in ELECTRONIC MEDICAL RECORD to verify the current status of resident's skin. Any new areas identified will be reported to the MD, orders obtained will be implemented and communicated to the wound nurse, DON and clinical team via ELECTRONIC MEDICAL RECORD Risk Management, 24 hr. report, and/or Hey Wound Team Notice. The care plan will be updated, a change in condition documentation will be completed, and RP will be notified. 14. Residents with pressure ulcers and significant wounds will be assessed and followed by the visiting Wound Physician and orders will be implemented by the center. Any changes made by the Wound Physician will be communicated to the resident's family and documented in the progress note in ELECTRONIC MEDICAL RECORD. DON and Nurse Managers will review wound reports and skin checks during the weekly at the clinical risk meeting to ensure the plan of care of residents with wounds and pressure ulcers are being followed. 15. The center will conduct a weekly skin at risk meeting by the clinical interdisciplinary team (consisting of ADON (Assistant Director of Nursing), MDS, Unit Managers, Wound Nurse, RN Supervisors) to ensure the plan of care of residents with wounds and pressure ulcers are being followed. 16. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the Medical Director and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the document titled Individualized Employee Education revealed Nurse #1 (LPN TT) was educated on [DATE] by the Administrator on Weekly Skin Assessments, Notification of Change, Following Physician Orders, and Abuse and Neglect Prohibition policy. The education was signed and dated [DATE] by the Administrator and Nurse#1. Review of a typed statement on the facility's letterhead revealed on [DATE] the Healthcare Staffing Agency was notified that the facility would no longer be utilizing Nurse #1, LPN (LPN TT) for any further shifts. Signed by The Administrator and the Healthcare Staffing Agency representative. This was confirmed via telephone interview on [DATE] at 10:47 a.m. with the Healthcare Staffing Agency representative. Review of a typed statement on the facility's letterhead by the Administrator revealed she electronically submitted a complaint to the Georgia Board of Nursing regarding LPN TT and is awaiting a confirmation receipt. Reference number provided. 2. Review of the document titled Individualized Employee Education revealed Nurse #2 (LPN VV) was educated on [DATE] by the Administrator on Weekly Skin Assessments, Notification of Change, Following Physician Orders, and Abuse and Neglect Prohibition policy. The education was signed and dated [DATE] by the Administrator and Nurse#2 (LPN VV). This was confirmed by interview with the Administrator on [DATE] at 3:05 p.m. 3. Review of the separation notice for the previous wound nurse (LPN OO) revealed employment ended [DATE]. Circumstances of separation - voluntary resignation. Signed by the Administrator on [DATE]. 4. Review of the facility in-service document revealed that a 1:1 phone/teleconference review of the Performance Improvement Plan (PIP) dated [DATE], education on Standards of Practice, EMR Order Entry, Documentation/Notification, Abuse and Neglect was conducted by the Medical Director with the Nurse Practitioner (NP) GG. NP GG was educated on the Process of Care including the following components: Assessment of Health Status, Diagnosis, Development of a Comprehensive Plan of Care, Implementation of the Plan, Follow up and evaluation of the patient status. Review of a typed statement on the facility's letterhead by the Administrator revealed she electronically submitted a complaint to the Georgia Board of Nursing regarding NP GG and is awaiting a confirmation receipt. Reference number provided. Review of a typed statement on the letterhead of Medical Director Services, PC dated [DATE] revealed: To Whom It May Concern: This is to verify that the NP (GG) was removed from working at the facility on [DATE]. An interview on [DATE] at 1:38 p.m. with the Medical Director (MD) revealed the NP was educated on the components of conducting a comprehensive, focused exam. The NP was counseled on the importance of assessing a resident's lower extremities and not assessing the resident's lower extremities was unacceptable. He also stated she was educated on communicating with the staff and follow-up with residents/staff to be sure orders were followed through and reassessment of residents (if required). He also reviewed the policy on Abuse and neglect with the NP. The MD stated the NP was not in agreement with the job requirements and a decision was made not to continue a working relationship with the NP. 5. Review of the Internal Policy Review Form dated [DATE] revealed the Abuse Prohibition Policy was reviewed by the Medical Director, Regional Director of Operations and Clinical Services and the Administrator with no revisions made. This was confirmed by interview with the Medical Director on [DATE] at 1:38 p.m. 6. Review of the Resident Wound Interview Audit Tool revealed five residents were interviewed on [DATE] by the Administrator. The residents, R#5, R#22, R#25, R#26, and R#27 had a BIMS score of 12 through 15 indicating cognition intact. This was validated by interview on [DATE] at 1:10 p.m. with R#5, 1:15 p.m. with R#22, and 1:20 p.m. with R#27. Resident care plans were reviewed and updated if needed. 7. Review of the daily census sheet dated [DATE] revealed a total census of 101. Review of the IMG_0189.jpeg (facility using to document skin assessments) revealed three residents refused the skin assessment. Review of the total number of IMG_0189.jpeg sheets completed was 102 including the three residents that refused. SBAR (Situation, Background, Appearance, Review/Notify) were completed for all identified skin concerns with family and Physician notification documented. There were no further concerns related to abuse or neglect. During an interview on [DATE] at 10:35 a.m., the Regional Director of Clinical Services (RDCS) stated the facility document titled IMG_0189.jpeg are Body Audits. The change in condition (CIC) and SBAR are the same assessment tools. The task started on [DATE] and was completed on [DATE]. She stated the LPN's and MDS Coordinators completed 99 resident body audits and three residents refused the skin assessment. She stated the Body Audits were compared with the previous skin sweep ([DATE] and [DATE]) and the last two skin checks in the electronic health record. They reviewed the documentation for progress notes, notification of the Physician and Responsible Party, orders that were carried out, completion of the CIC/SBAR and an update of the care plan. 8. Review the of the statement on the facility letterhead dated [DATE] signed by the RDCS revealed the Body Audits from the house skin sweep were reviewed. The RDSC noted six residents with new areas. The statement further stated that the Physician and RP were notified. The findings were reported to the Administrator and DON. Finding were shared during the AD HOC Committee meeting. An interview was conducted on [DATE] at 11:19 a.m. with the RDCS. She confirmed review of all body audit sheets for change in condition, and to validate Physician and RP notification. The information was communicated to the Administrator and the DON. 9. A review of the grievance log for [DATE] to [DATE] revealed no documented skin issues. A review the of the statement on the facility letterhead dated [DATE] signed by the Administrator revealed over the last 60 days there was seven grievance; none were related to skin concerns. AD-HOC/Quality Assurance (QA) and Performance Improvement (PI) meeting sign in sheet dated [DATE] revealed the Administrator, Medical Director, Regional Director of Clinical Service, Director of Clinical Service, and the Director of Nursing via phone conference were in attendance. 10. A review of the facility in-service record dated [DATE] revealed the Administrator and DON were educated on Abuse and Neglect by the RDO. Policy GA Abuse Prohibition-State of Georgia with an effective date of ,[DATE] and reviewed date of [DATE], the policy revealed Centers will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: Screening of potential hires, Training of employees, Prevention, Identification, Investigation, Protection, and Reporting/Response. An interview was conducted on [DATE] at 3:40 p.m. with the Administrator. She stated she had been orientated on the abuse and neglect policy by the RDO. The Administrator stated that of all staff are in-serviced during orientation process and quarterly on Abuse and neglect. 11. Review of facility in-service record dated [DATE] revealed 7 RN's, 31 LPN's, one Nurse Practitioner (NP) and 52 CNA's received education on the abuse and neglect policies and procedures. This included Agency staff and an additional 36 signatures that included administrative staff, dietary, therapy, housekeeping (HK)/laundry, and activities. Also verified the above in-services via the following staff interviews on [DATE] at 11:45 a.m. with RN JJ; [DATE]: 6:42 a.m. with LPN UU, 6:45 a.m. with CNA WWW, 6:48 a.m. with CNA BBBB, 6:52 a.m. with CNA OOO, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; [DATE]: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; [DATE]: 1:50 p.m. with CNA CCCC and 2:53 p.m. with CNA EEEE; [DATE] at 11:01 a.m. with RN KK; and [DATE] at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Also verified the above in-services via the following staff interviews on [DATE]: 11:35 a.m. with Floor Tech NNNN, 11:41 a.m. with HK QQQQ, 11:52 a.m. with Account Manager MMMM, 11:57 a.m. with the Director of Marketing, 12:05 p.m. with the Maintenance Director, 1:00 p.m. with the dietary aide UUUU, 1:02 p.m. with Staff VVVV, and 1:05 p.m. with dietary aide WWWW. 12. Review of the weekly Clinical Skin System Audit Tool starting [DATE] revealed skin assessments were completed daily per the skin assessment schedule. The Physician, RP, and Wound nurse were notified of identified skin issues. The audits were reviewed weekly and signed by the DON, ADON, Wound Nurse, RN Supervisor, and the MDS Coordinator. 13. R#15, R#29, R#31, R#37, R#38, and R#39 had skin assessments completed as scheduled and reported timely to the family and Physician. No concerns were identified. During an interview on [DATE] at 2:33 p.m., the DON stated that the Charge Nurses are completing the weekly skin checks on the residents and if the skin check reveals a new skin concern, it flags for a Braden Scale to be completed. If the Braden Scale reflects a resident to be at HIGH risk for pressure ulcer, then the treatment nurse will re-assess the resident and if the assessment is accurate, treatment orders will be implemented, and care plan will be updated. The Physician and the responsible party will be notified as well as making sure orders are followed through. 14. A review of the Weekly Wound Management Tracking Tool dated [DATE], [DATE], and [DATE] revealed the Wound Care Team was in the facility and saw 12 of 12 residents on the list. Review of the Progress Notes for the residents with wounds revealed no issues noted. 15. A review of the weekly At-Risk Meeting sign in sheet dated [DATE] signed by the DON, ADON, Wound Nurse, and RN supervisor. The minutes revealed the facility discussed the residents on the Wound Management Tracking Tool, the residents identified in the skin sweep on [DATE] and [DATE], and the updated skin check schedule. The interdisciplinary team (IDT) also discussed Braden Scores, notification, and the EMR communication board. A review of the weekly At-Risk Meeting sign in sheet dated [DATE] signed by the DON, ADON, Wound Nurse, and Wound Team. The minutes revealed a discussion of five residents that are currently being treated for [REDACTED].

Based on record review, review of the Georgia Rule ,[DATE]-.01 Standards of Practice for Registered Professional Nurses, Georgia Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, and Georgia Rule ,[DATE]-.03 Standards of Practice for Nurse Practitioners and resident/ staff interviews, the facility failed to ensure that services were provided in accordance with professional standards of quality as evidenced by the failure to conduct weekly skin assessments and failure to act upon identified skin concerns for one resident (R) (#1) of 36 sampled residents. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 1:45 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: R#1 was readmitted to the facility on [DATE]. On [DATE], staff identified the first three digits of the left foot to be black and discolored. The Physician was not notified. On [DATE], staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On [DATE], staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Findings include: Review of the Georgia Rule ,[DATE]-.01 - Standards of Practice for Registered Nurses revealed that: 2. (a) 3. Plan care which includes goals and prioritized nursing approaches, or measures derived from the nursing diagnoses; (b) 3. Communicate, collaborate and function with other members of the health team to provide optimum care; 8. Assign and supervise only those nursing measures which the nurse knows, or should know, that another person is prepared, qualified, or licensed to perform; 9. Retain professional accountability for nursing care when delegating nursing intervention. Review of the Georgia Rule ,[DATE]-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a Physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. Review of the Georgia Rule ,[DATE]-.03 - Standards of Practice for Nurse Practitioners revealed that: Review of the Georgia Board of Nursing ,[DATE]-.03: Standards of Practice for Nurse Practitioners, 2. (a) The nurse practitioner provides advanced practice nursing care and medical services specific to the nurse practitioner respective specialty to individuals, families and groups, emphasizing health promotion and disease prevention as well as the [DIAGNOSES REDACTED]. The nurse practitioner collaborates as necessary with a variety of individuals to diagnose and manage clients' health care problems. A review of the Admission Record (face sheet) for R#1 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 3 out of 15, which indicated severe cognitive impairment. Section G documented the resident as requiring extensive assistance with bed mobility, transfer, personal hygiene dressing, and toilet use. Section M revealed the resident was high risk for pressure ulcer but had no pressure ulcers, venous, or arterial ulcers in this assessment period. Pressure ulcer triggered as an area of concern on the Care Area Assessment Summary (CAAS). A review of the care plan dated [DATE] revealed that R#1 is at risk for pressure ulcers related to her frequent incontinence of bowel and bladder and her decreased mobility. Goal: R#1 will maintain intact skin integrity with no pressure ulcers through next review. Interventions: Check for incontinence frequently, observe skin condition with ADL care daily and report abnormalities. Evaluate for any localized skin problems, i.e dryness, redness, pustules, inflammation, etc. Notify charge nurse as indicated. Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury). Weekly skin assessments. A review of the Electronic Medical Record (EMR) for R#1 revealed a Physician order [REDACTED]. There was no documented evidence that the facility was conducting a weekly skin check on R#1 as ordered on [DATE] by the Physician. The last documented skin check was on [DATE]. The EMR, Skin Check dated [DATE] revealed: The left foot, the first three digits of foot are black and discolored. Patient complained of pain and discomfort in foot. Patient given something for pain. Another nurse was called into to look. There was no documented evidence that the nurses notified the Physician and family of the resident's change in condition. A review of Nurse Practitioner Encounter dated [DATE] revealed: resident was seen in her/his room today while in bed. She is seen today for the management and treatment of [REDACTED]. Health Status: The patient was seen and examined. General: No acute distress. Well developed. Alert in no distress Eye: Pupils are equal, round, and reactive to light, extraocular movements are intact. Head Eyes Ears Neck Throat (HENT) {sic}: Normocephalic, atraumatic, without obvious abnormality Neck: Supple, Non-tender. Trachea midline Respiratory: Lungs clear to auscultation; Respirations are non-labored. Effort normal Cardiovascular: Normal S1, S2 (first and second heart sound), Normal rate, Regular rhythm. Intact distal pulses. Gastrointestinal: Soft, Non-tender. Normal active Bowel sounds + (positive)X4 (all four quadrants). Integumentary: Warm, Clean, Dry. Mental status/ Cognition: Alert, Oriented X3 (person place and time). A review of the EMR Wound/Skin Note dated [DATE] revealed: Asked to observe left foot (the writer). First three toes of left foot, with necrotic, devitalized tissue, with small open areas. A telephone order received for the NP for [MEDICATION NAME] daily, have the Wound Physician see the resident and for Arterial Doppler study ASAP (as soon as possible). The telephone order was transposed to the EMR although there was no evidence of follow through for these orders. No evidence that the family was notified. A review of the EMR Nurse's Note dated [DATE] revealed: Wound to resident's left foot noted to have deteriorated. Director of Nursing (DON) and NP contacted. Nurse Practitioner given assessment and new orders to send out for evaluation and treatment of [REDACTED]. Resident transported to the local Hospital. A review of the hospital emergency room (ER) records dated [DATE] revealed: Chief Complaint patient presents with maggots to left toes. A review of the Hospital Operative Note dated [DATE] revealed: Findings: preoperative diagnosis-gangrenous left foot infested with maggots, with procedure left [MEDICAL CONDITION] (LBKA). A review of the Hospital Pathology Report dated final report [DATE] revealed [MEDICAL CONDITION] The distal part of the foot is necrotic and is black in color. Live maggots are noted in the ulcerated necrotic areas, involving all the toes. These maggots measured 1.2 inches in length each. A telephone interview on [DATE] at 10:30 a.m. with Physician BB revealed on Saturday [DATE] a resident from the facility was brought into the emergency room for a complaint of infected toes on the left foot. Physician BB reported upon examination of R#1 her left foot was embodied with maggots. Physician BB stated he did not count the maggots, but it was a lot. Physician BB stated on Sunday [DATE], R#1's left leg had to be amputated. An interview was conducted on [DATE] at 11:15 a.m. with NP GG who stated she received a call and pictures on [DATE] informing her of the condition of R#1's left foot. She was informed by the caller that R#1 toes on left foot were dark. NP GG revealed the last time she saw R#1 was on [DATE] and on [DATE] the day before she was sent out to the hospital. NP GG stated she did not assess the resident's feet on [DATE] and she did not assess the left foot on [DATE]. NP GG stated she does not look at any resident's feet. An interview on [DATE] at 12:30 p.m. with Licensed Practical Nurse (LPN) JJJ revealed on Saturday [DATE] at approximately 11:20 a.m. two Certified Nursing Assistants (CNA) asked her to come and assess R#1 left foot. LPN JJJ revealed when she arrived in the room and to assess R#1 left foot she noted all the resident toes on the left foot were black and the foot was infested with maggots. She stated during the assessment R#1 exhibited signs of pain and discomfort. The resident pulled her left foot away when touched and made noises as if she were in pain. She stated the DON and NP were notified immediately and the DON was provided with a picture. The NP gave orders to send to R#1 to the ER. LPN JJJ stated she wrote a statement and instructed the two CNA's to also write a statement. She further revealed that the statements were provided to the DON. An interview on [DATE] at 12:45 p.m. with R#11 (roommate of R#1 with BIMS of 13, indicating cognition intact) revealed that R#1 would complain all the time that her feet were hurting. R#11 stated when R#1 would complain to her she would put her light on and let the nurse know. She stated she does not remember if the staff would look at the resident's feet when she complained. An interview on [DATE] at 1:00 p.m. with CNA ZZZ revealed that on [DATE] between 10:30 a.m.-11:30 a.m., she went in R#1's room to give her a bed bath for the day. The resident had complaints of discomfort of the left foot. CNA ZZZ stated when she looked at R#1 left foot it was leaking maggots. She stated it was so many maggots in the residents left foot and on the bedding. She asked her coworker to have the nurse to come into the room. At that point she attempted to clean the maggots out with the washcloth, and she used two clothes that were full of maggots. CNA ZZZ stated around a thousand of maggots was inside of R#1's foot and she could hear the maggots making a scratching sound. Interview on [DATE] at 1:35 p.m. with LPN TT revealed that on [DATE] a CNA asked her to go and assess R#1 because the patient was itching. She stated R#1 told her that she was not itching, her left foot was hurting. She stated upon assessing the resident's left foot the third toe looked like a raisin (wrinkled) and the toe looked like it was going to fall off and the second toe on the left foot was purple. She stated she asked another nurse to come asses the residents left foot. LPN TT stated she did not notify the Physician, family, or DON. LPN TT stated she did not know where to look for the family or the Physician's number. She stated she did have the DON's number but failed to call the DON. She stated, it was poor judgement not notifying the Physician and the family. LPN TT stated she has never received an orientation on the facility's policy and procedures. LPN TT stated she has never completed a skin check in the EMR on R#1. A telephone interview on [DATE] at 2:01p.m. with LPN OO revealed that on Wednesday [DATE] one of the CNA's approached her and ask that she assess R#1's left foot. She stated R#1 toes on the left foot were black and necrotic with some open areas. LPN OO stated she sent a picture to the NP of R#1 left foot. She stated she also called the NP and was given orders to schedule R#1 to see the facilities Wound Physician on [DATE], [MEDICATION NAME] daily, and arterial doppler study. Review of the picture taken on [DATE] of R#1's foot revealed the first three toes were black. Two maggots were visible on the top of R#1's foot near the third toe. An interview on [DATE] at 10:30 a.m. with LPN SS revealed she was never orientated on completing weekly skin check and does not know where to locate the skin check for documentation in the facility's EMR. An interview on [DATE] at 12:30 p.m. with the Medical Director (MD) revealed the NP made him aware of R#1's left foot on [DATE]. The MD stated the NP did not provide him with the picture. He stated he instructed her to order a Doppler and have the resident seen by the Wound Physician the next day. The MD stated if he had seen the picture of the resident's foot, he would have given an order to send her to the hospital. An interview was conducted on [DATE] at 1:54 p.m. with the DON who stated she did not investigate why or how R#1 had necrotic toes that were infested with maggots. The DON stated the finding of R#1's toes black with maggots was not abuse or neglect. What happened to R#1 was unfortunate. She stated the staff neglected to complete a weekly skin check and did not follow Physician/NP orders. The DON stated her expectation is that the resident's baths and skin report are completed by the CNA's as assigned, and the residents weekly skin check should be completed by the licensed nursing staff as assigned. An interview was conducted on [DATE] at 8:50 a.m. with Wound Physician AA. He stated he makes rounds at the facility every Thursday. Wound Physician AA stated he was in the facility on [DATE] and he was not asked to assess R#1's left foot. He further stated he would have seen the resident if he had been notified. An interview on [DATE] at 3:25 p.m. with the Administrator revealed she became aware of R#1's left foot on [DATE] after receiving a call from the DON. The Administrator stated she did not consider the incident with R#1 to be abuse or neglect. An interview on [DATE] at 1:00 p.m. with CNA DDDD revealed she worked a double shift on a Wednesday [DATE]. On the evening shift (3:00 p.m.) while providing incontinent care to R#1 she noticed her left foot toes were dark. She stated it was reported to the nurse that the resident toes were dark, and she was told by the nurse that she would go and assess the resident. The facility implemented the following actions to remove the IJ: 1. Licensed Nurse (s) #1 was educated by Administrator on center Notification of Change, following Physician order [REDACTED]. On [DATE] agency employee will no longer be utilized by this center and will be reported to the Georgia Board of Nursing. 2. Licensed Nurse (s) #2 was educated by Administrator on center Notification of Change, following Physician order [REDACTED]. 3. Wound Nurse no longer employed at this center 4. Medical Director educated NP on patient assessments and Abuse and Neglect Prohibition Policy on [DATE]. On [DATE] NP will no longer be utilized by this center and will be reported to the Georgia Board of Nursing. 5. On [DATE] the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy (s) Physician Services and Standard of Clinical Nursing Care. No policy changes or recommendations were made as a result of this review. 6. Residents identified as high risk for developing pressure ulcers on their Braden Scale assessment will have a weekly skin re-assessment by the Nurse Managers to make sure all impaired skin has been assessed and captured, with MD and RP notification and orders implemented per Physician Orders. The Body Audit Tool will be utilized as the assessment tool. 7. Administrator re-educated licensed nursing (RNs 5 of 6 -83%; LPNs 22 of 25 -88%/ Agency : LPNs 6 of 7- 86%) employees on skin change in condition requirements (MD notification, receiving and implementing Physician orders, communication of updated plan of care and family notification). Teleconference/phone in-servicing was provided to RN 1, LPNs 3 on [DATE]. Employees on leave of absence FMLA- (3 LPNs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 8. Director of Nursing and Unit Managers will review all new wound care orders in the electronic medical record daily clinical meeting to validate their implementation and to make sure they are being followed appropriately. Findings will be logged on the Clinical Meeting Audit Tool 9. Center hired an experienced wound nurse on [DATE] to help champion the skin integrity system and improve skin outcomes. Another new hire RN wound nurse to start [DATE] to provide additional oversight to the Skin Integrity Management Program. 10. On [DATE] center contracted with a new Wound Physician group to come to the center on an on-going basis to address residents with wounds and significant skin conditions. Wound Physician will assess, evaluate, treat all residents identified with wounds based on the wound nurse weekly wound report, any new rep01ied wounds or guidance/referral of the wound nurse. 11. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting weekly for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the Physician and the members of the committee. Subsequent plans of corrections will be implemented, as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the document titled Individualized Employee Education revealed Nurse #1 (LPN TT) was educated on [DATE] by the Administrator on Weekly Skin Assessments, Notification of Change, Following Physician Orders, and Abuse and Neglect Prohibition policy. The education was signed and dated [DATE] by the Administrator and Nurse#1 (LPN TT). Review of a typed statement on the facility's letterhead revealed on [DATE] the Healthcare Staffing Agency was notified that the facility would no longer be utilizing Nurse #1 , LPN TT for any further shifts. Signed by The Administrator and the Healthcare Staffing Agency representative. This was confirmed via telephone interview on [DATE] at 10:47 a.m. with the Healthcare Staffing Agency representative. Review of a typed statement on the facility's letterhead by the Administrator revealed she electronically submitted a complaint to the Georgia Board of Nursing regarding LPN TT and is awaiting a confirmation receipt. Reference number provided. 2. Review of the document titled Individualized Employee Education revealed Nurse #2 (LPN VV) was educated on [DATE] by the Administrator on Weekly Skin Assessments, Notification of Change, Following Physician Orders, and Abuse and Neglect Prohibition policy. The education was signed and dated [DATE] by the Administrator and Nurse#2 (LPN VV). This was confirmed by interview with the Administrator on [DATE] at 3:05 p.m. 3. Review of the separation notice for the previous wound nurse (LPN OO) revealed employment ended [DATE]. Circumstances of separation - voluntary resignation. Signed by the administrator on [DATE]. 4. Review of the facility in-service document revealed that a 1:1 phone/teleconference review of the Performance Improvement Plan (PIP) dated [DATE], education on Standards of Practice, EMR Order Entry, Documentation/Notification, Abuse and Neglect was conducted by the Medical Director with the Nurse Practitioner (NP) GG. NP GG was educated on the Process of Care including the following components: Assessment of Health Status, Diagnosis, Development of a Comprehensive Plan of Care, Implementation of the Plan, Follow up and evaluation of the patient status. Review of a typed statement on the facility's letterhead by the Administrator revealed she electronically submitted a complaint to the Georgia Board of Nursing regarding NP GG and is awaiting a confirmation receipt. Reference number provided. Review of a typed statement on the letterhead of Medical Director Services, PC dated [DATE] revealed: To Whom It May Concern: This is to verify that the NP (GG) was removed from working at the facility on [DATE]. An interview was conducted on [DATE] at 1:38 p.m. with the Medical Director (MD). He stated the NP (GG) was educated on the components of conducting a comprehensive, focused exam. The NP was counseled on the importance of assessing a resident's lower extremities and not assessing the resident's lower extremities was unacceptable. He also stated she was educated on communicating with the staff and follow-up with residents/staff to be sure orders were followed through and reassessment of residents (if required). He also reviewed the policy on Abuse and neglect with the NP. The MD stated the NP was not in agreement with the job requirements and a decision was made not to continue a working relationship with the NP. 5. An interview was conducted on [DATE] at 1:15 p.m. with the Medical Director. He stated the facility reviewed the Physician Services and Standard of Clinical Nursing Care policies on [DATE] (via phone). The facility revealed the policy in place did not require any changes. 6. Review of the facility documentation for Braden Scale completed from [DATE] through [DATE] revealed there was a total of five residents who were identified by facility staff to be at high risk for developing pressure ulcers on their Braden Scale. R#15, R#29, R#31, R#37, R#38, and R#39 had skin assessments completed as scheduled and reported timely to the family and Physician. No concerns were identified. During an interview on [DATE] at 2:33 p.m., the DON stated that the Charge Nurses are completing the weekly skin checks on the residents and if the skin check reveals a new skin concern, it flags for a Braden Scale to be completed. If the Braden Scale reflects a resident to be at HIGH risk for pressure ulcer, then the treatment nurse will re-assess the resident and if the assessment is accurate, treatment orders will be implemented, and care plan will be updated. The Physician and the Responsible Party will be notified as well as making sure orders are followed through. 7. Review of facility in-service record dated [DATE] revealed 7 RN's and 32 LPN's received education on change in condition requirements, reporting to Physician and Responsible Party, receiving, and implementing Physician orders [REDACTED]. Also verified the above in-services via the following staff interviews on [DATE] at 11:45 a.m. with RN JJ; [DATE]: 6:42 a.m. with LPN UU, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; [DATE]: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; [DATE] at 11:01 a.m. with RN KK; and [DATE] at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 8. Review of facility Clinical Audit Tool starting [DATE] revealed that the DON reviewed scheduled daily skin checks to ensure that nursing staff were completing skin checks and if newly identified skin issues were being followed through with Physician and Responsible Party notifications. For the week of [DATE] through [DATE], there were four residents identified to be at high risk for developing pressure ulcers on their Braden Scale. These residents had Physician orders [REDACTED]. Their care plans have been updated to indicate residents at risk for pressure ulcers. Interview on [DATE] at 3:59 p.m. the DON stated that during the Daily Clinical Meeting, they discuss any issues with residents including skin concerns. She stated she reviews all the daily skin checks and if the nurses have identified a new skin concern, she verifies that the Physician has been notified and orders received and implemented and that the Responsible Party is notified and the care plan updated. 9. Review of the Wound Nurse/Rehabilitation Nurse job description revealed employee, LPN NN, accepted responsibilities of the position on [DATE]. On [DATE], a second Wound Nurse, RN KK, began employment to provide additional oversight to the Skin Integrity Management Program. Interview on [DATE] at 4:29 p.m. with LPN NN revealed that she was informed about the wound care situation at the facility when she was hired. She stated that she accepted the responsibilities of her job description and that she has gotten good support from the administrative staff. She stated that she has plenty of supplies to take care of the residents wound care needs. She has more than [AGE] years experience providing wound care. Interview on [DATE] at 11:01 a.m. with RN KK revealed that she has been in orientation since her hire date of [DATE]. She stated that she will be working day shift and will share the wound care responsibilities with LPN NN. She stated that she was informed about the situation with the wound care system when she was hired. She further stated that she and LPN NN have been working to ensure that wound care is covered seven days per week. 10. Review of a contract with the Wound Physician Group and the facility revealed that the Wound Physician Group agrees to provide Physician related wound, ostomy, and skin care services to all patients within the facility for whom wound, ostomy and skin care consultation has been requested. Interview on [DATE] at 10:48 a.m. with Physician EE revealed that she began seeing residents in the facility on [DATE] and will be making her weekly visits on Thursdays. 11. Review of the QAPI Meeting Minutes dated [DATE] revealed the RDO, RDCS, ADON, Admission Director, Activities Director, Environmental Service Manage, Maintenance, Marketing Director, MDS Coordinators, and the Dietary Manager were in attendance. Specific Subject Matter Topics: IJ Issuance and Abatement Plan, skin audits, wound log, reviewed the purpose of the weekly at-risk meeting, concerns identified, communication, policy review, QAPI schedule, and staff education. Review of the QAPI Meeting Minutes dated [DATE] signed by the Medical Director, Administrator, DON, Admission Director, Wound Nurse, ADON, Activities Director, Environmental Service Manager, Maintenance, Marketing Director, RN Supervisors, MDS Coordinators, and the Dietary Manager. Specific Subject Matter Topics: audits, skin integrity, baths, staffing, new PIP (process improvement plan). Review of a typed statement on the facility's letterhead revealed daily and weekly skin audits (Clinical Skin System Audit Tool) results were reviewed by the Administrator with Physician and QAPI committee attendees on [DATE], [DATE] and [DATE]. Audit results will continue to be reviewed at each subsequent QAPI meeting. Reviewed by phone with Medical Director on [DATE]; all other communication done in person. Signed by the Administrator. Interview on [DATE] at 2:27 p.m. with the Administrator revealed she reviewed each of the facility audit reports and reports to the Medical Director and Interdisciplinary Team during QAPI meetings.

Based on record review, review of the facility policy titled Person-Centered Care Plan, and staff interviews, the facility failed follow the care plan related to weekly skin assessments for one resident (R) (#1) and failed to develop a care plan related to [MEDICAL TREATMENT] for one resident (R#10) of 36 sampled residents. Actual harm was identified when R#10 was hosptalized on [DATE] for complications related to not receiving [MEDICAL TREATMENT]. On 10/16/2020 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator, Regional Director of Operations (RDO), and Regional Director of Clinical Services (RDCS) were informed of the Immediate Jeopardy (IJ) on 10/16/2020 at 1:45 p.m. The noncompliance related to the IJ identified to have existed on 9/13/2020 when staff failed to act after discovering R#1 with black toes. The IJ is outlined as follows: R#1 was readmitted to the facility on [DATE]. On 9/13/2020, staff identified the first three digits of the left foot to be black and discolored. The Physician was not notified. On 9/16/2020, staff identified the first three toes of the left foot with necrotic, devitalized tissue and small open areas. The Nurse Practitioner (NP) was notified and ordered a Wound Physician consult, [MEDICATION NAME] daily and arterial doppler. There was no evidence that nursing staff carried out the NP orders. On 9/19/2020, staff identified that the left foot had deteriorated. The NP was notified and ordered to send R#1 to the hospital for evaluation and treatment of [REDACTED]. R#1 presented to the hospital with gangrenous left foot infected with maggots and had a left [MEDICAL CONDITION]. The IJ was related to the facility's noncompliance with the program requirements as follows: 42 CFR 483.10 Notification of Changes (F580 Scope and Severity (S/S): J) 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) 42 CFR 483.21 Comprehensive Care Plans (F656 S/S: J) 42 CFR 483.21 Services Provided Meet Professional Standards (F658 S/S: J) 42 CFR 483.25 Quality of Care (F684 S/S: J) 42 CFR 483.70 Administration (F835 S/S: J) 42 CFR 483.75 Quality Assurance and Performance Improvement/Quality Assessment and Assurance (F867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 S/S: J) and 42 CFR 483.25 Quality of Care (F684 S/S: J). An Acceptable IJ Removal Plan was received on 10/26/2020. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/20/2020. The facility remained out of compliance at a lower scope and severity as follows: F580 S/S: D; F600, S/S: D; F656 S/S: D; F658 S/S: D; F684 S/S: D; F835 S/S: D; and F867 S/S: D while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the skin integrity program and neglect. Findings include: A review of the facility policy titled Person-Centered Care Plan effective date 8/2019 indicated: A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives . The care plan will be reviewed and revised by the interdisciplinary team after each assessment. A comprehensive person-centered care plan must be developed for each patient and must describe the following: 4.1 Services that are to be furnished. 7. Care plans will be communicated to appropriate staff. 1. A review of the Admission Record (face sheet) for R#1 revealed she was admitted to the facility on [DATE] and a readmission on 12/19/2017 [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. Section M revealed the resident is at risk for developing pressure ulcer and had no pressure ulcers, venous, or arterial ulcers. A review of the care plan dated 1/6/2020 revealed R#1 is at risk for pressure ulcer related to frequent incontinence of bowel and bladder and her decreased mobility. Intervention included weekly skin assessments. Observe skin condition with ADL care daily and report abnormalities. Review of the Skin Check in the Electronic Medical Record (EMR) for R#1 revealed last skin check completed on 4/7/2020 revealed no identified skin issue. No bath sheets (body audits during a bath) were available for review. Further review of the clinical record revealed on 9/13/2020, R#1 was observed to have three black toes. On 9/19/2020, the resident was sent to the hospital with maggots in left foot. Interview on 9/30/2020 at 1:35 p.m. with LPN TT revealed on 9/13/2020 a CNA asked her to go and assess R#1. She stated upon assessing the resident's left foot the third toe looked like a raisin (wrinkled) and the toe looked like it was going to fall off and the second toe on the left foot was purple. LPN TT stated she has never received an orientation on the facility's policy and procedures regarding skin assessments and has never completed a skin check in the EMR on R#1. Cross refer to F684. 2. Review of the clinical record for R#10 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital discharge paperwork printed 6/25/2020 at 3:15 p.m. by Admissions Director RRRR, revealed R#10 was discharged from the hospital with [MEDICAL TREATMENT] Catheter (Vascath - Central Venous Catheter inserted into a vein located in either the neck or the groin) to the right side of neck placed on 6/1/2020. Review of the Physician's Orders for the month of June 2020 revealed no evidence that a Physician Order was obtained for [MEDICAL TREATMENT] after admission. Review of care plan for R#10, initiated 6/25/2020, revealed resident did not have a care plan problem to include the need for [MEDICAL TREATMENT], related to [DIAGNOSES REDACTED]. R#10 was sent back to the hospital on [DATE]. Review of the Hospital Records for admitted [DATE] revealed R#10 was hospitalized with concerns related to [MEDICAL CONDITION]. Review of the clinical record for R#10 revealed she was readmitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 14, indicating no cognitive impairment. Section O documented R#10 was receiving [MEDICAL TREATMENT] while a resident in the facility. Review of care plan for R#10 last updated 7/22/2020 revealed resident did not have a care plan problem to include the need for [MEDICAL TREATMENT] related to a [DIAGNOSES REDACTED]. An interview on 10/8/2020 at 10:05 a.m. with MDS Coordinator PP revealed that care plans should be updated seven days after an MDS is completed. MDS PP revealed any nurse in the facility can update a care plan. She stated all care plans should be reviewed/revised during the residents' assessment period. Cross refer to F698. The facility implemented the following actions to remove the IJ: 1. RI (Resident) #1 no longer resides at the facility 2. On 10/18/2020 the Regional Director of Operations, Regional Director of Clinical Services and Medical Director reviewed the center policy Care Plan. No policy changes or recommendations were made as a result of this review. 3. A second set of whole house (99 of 102 residents with 3 refusals) skin assessments was completed on October 16 -17 (2020) by the center charge nurses to identify any additional skin concerns. Any new concerns identified will be documented on the body audit sheet, reported to the MD and any orders obtained will be implemented. Resident plans of care were reviewed and updated as needed, and responsible parties will be notified 4. On October 16 - 17, 2020 the Director of Clinical Services reviewed all body audit sheets for change in condition, and to validate MD and RP notification. Review was documented on the Skin Audit Tool and shared with the Administrator and Director of Nursing. Plans of care were updated as needed according to the notations on the body tool. 5. Licensed nurses (RNs 5 of 6 -83%; LPNs 22 of 25 -88%/Agency: LPNs 6 of 7- 86%) were educated by Administrator on the importance of completing and documenting scheduled weekly skin assessment on 10/17/2020. Teleconference/phone in-servicing was provided to RN 1, LPNs 3 on October 19, 2020. Employees on leave of absence FMLA- (3 LPNs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 6. The Director of Reimbursement provided additional education to center Nurse Managers and MDS team on Person-Centered Care Plan to include development, implementation, and revision of care plans on October 16 - 17, 2020 7. The Administrator re-educated licensed nurses (RNs 5 of 6 -83%; LPNs 22 of 25 -88%;/ Agency: LPNs 6 of 7- 86%) on identification of altered skin integrity with the development and revision of person center care plan to address skin concerns. Teleconference/phone in-servicing was provided to RN 1, LPNs 3 on October 19, 2020. Employees on leave of absence FMLA- (3 LPNs), vacation (1 RN) or agency staff will be re-educated prior to returning to duty and will not be given an assignment until they are given additional on-site education. 8. The Director of Nursing will review skin checks from the previous day during daily clinical meeting and will verify care plans are developed and revised as needed, to address not only treatments but interventions to prevent wound development and pressure ulcers. 9. Administrator will review the results of the audits in the weekly Quality Assurance Performance Improvement meeting weekly for four weeks then monthly to ensure compliance is achieved and sustained. Administrator will sign and communicate results of the audit review with the Physician and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the facility census list revealed billing stopped for R#1 on 9/26/2020 which was her discharge date . Interview with the Family of R#1 on 11/5/2020 at 9:30 a.m. revealed that the resident was discharged from the hospital and currently resides at a different nursing home. 2. Review of the Internal Policy Review Form dated 10/18/2020 revealed facility policy titled Care Plan was reviewed with no revisions as indicated by signatures of the Administrator, Director of Operations, Director of Clinical Services and Medical Director (via teleconference). Interview with the Medical Director on 10/30/2020 at 1:38 p.m. revealed the policy was reviewed and did not need any changes. 3. Review of the daily census sheet dated 10/16/2020 revealed a total census of 101. Review of the IMG_0189.jpeg (facility using to document skin assessments) revealed three residents refused the skin assessment. Review of the total number of IMG_0189.jpeg sheets completed was a 102 including the three residents that refused. SBAR (Situation, Background, Appearance, Review/Notify) were completed for all identified skin concerns with family and Physician notification documented. R#15, R#29, R#31, R#37, R#38, and R#39 had findings from the skin assessments reported timely to the family and Physician and the care plan was updated. During an interview on 11/4/2020 at 10:35 a.m., the Regional Director of Clinical Services (RDCS) stated the facility document titled IMG_0189.jpeg are Body Audits. The change in condition (CIC) and SBAR are the same assessment tools. The task started on 10/16/2020 and was completed on 10/17/2020. She stated the LPN's and MDS Coordinators completed 99 resident body audits and three residents refused the skin assessment. She stated the Body Audits were compared with the previous skin sweep (9/22/2020 and 9/23/2020) and the last two skin checks in the electronic health record. They reviewed the documentation for progress notes, notification of the Physician and Responsible Party (RP), orders that were carried out, completion of the CIC/SBAR and an update of the care plan. 4. Review the of the statement on the facility letterhead dated 10/17/2020 signed by the RDCS revealed the Body Audits from the house skin sweep were reviewed. The RDSC noted six residents with new areas. The statement further stated that the Physician and RP were notified, and care plan were updated. The findings were reported to the Administrator and DON. Finding were shared during the AD HOC Committee meeting. An interview was conducted on 11/4/2020 at 11:19 a.m. with the RDCS. She confirmed review of all body audit sheets for change in condition, and to validate Physician and RP notification, and that the care plan was updated. The information was communicated to the Administrator and the DON. 5. Review of facility in-service record dated 10/16/2020 revealed 7 RN's and 32 LPN's received education on completing and documenting weekly skin assessments. 6. Review of facility in-service record dated 10/16/2020 revealed MDS Coordinators, DON, Nursing Supervisor, ADON, and Wound Care Nurse received education on identification of altered skin integrity with development and implementation of a revised care plan. Also verified the above in-services via a staff interview on 11/5/2020 at 3:15 p.m. with MDS Coordinator PP. 7. Review of facility in-service record dated 10/16/2020 revealed 7 RN's and 32 LPN's received education on the development and revision of a person-centered care plan. Also verified the above in-services via the following staff interviews on 10/26/2020 at 11:45 a.m. with RN JJ; 11/2/2020: 6:42 a.m. with LPN UU, 6:55 a.m. with LPN AAA, 7:15 a.m. with LPN KKK, 7:25 a.m. with LPN CCC, 11:08 a.m. with RN II, and 11:30 a.m. with LPN ZZ; 11/4/2020: 9:27 a.m. with LPN HHH and 9:52 a.m. with LPN YY; 11/6/2020 at 11:01 a.m. with RN KK; and 11/10/2020 at 10:50 a.m. with LPN RR, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 8. Review of the weekly Clinical Skin System Audit Tool starting 10/19/2020 revealed skin assessments were completed daily per the skin assessment schedule. The Physician, RP, and Wound nurse were notified of identified skin issues. The audits were reviewed weekly and signed by the DON, ADON, Wound Nurse, RN Supervisor, and the MDS Coordinator. R#15, R#29, R#31, R#37, R#38, and R#39 had skin assessments completed as scheduled and care plans were updated with no concerns identified. 9. Review of the QAPI Meeting Minutes dated 10/23/2020 revealed the RDO, RDCS, ADON, Admission Director, Activities Director, Environmental Service Manage, Maintenance, Marketing Director, MDS Coordinators, and the Dietary Manager were in attendance. Specific Subject Matter Topics: IJ Issuance and Abatement Plan, skin audits, wound log, reviewed the purpose of the weekly at-risk meeting, concerns identified, communication, policy review, QAPI schedule, and staff education. Review of the QAPI Meeting Minutes dated 10/30/2020 signed by the Medical Director, Administrator, DON, Admission Director, Wound Nurse, ADON, Activities Director, Environmental Service Manager, Maintenance, Marketing Director, RN Supervisors, MDS Coordinators, and the Dietary Manager. Specific Subject Matter Topics: audits, skin integrity, baths, staffing, new PIP (Process Improvement Plan). Review of a typed statement on the facility's letterhead revealed daily and weekly skin audits (Clinical Skin System Audit Tool) results were reviewed by the Administrator with Physician and QAPI committee attendees on 10/17/2020, 10/23/2020 and 10/30/2020. Audit results will continue to be reviewed at each subsequent QAPI meeting. Reviewed by phone with Medical Director on 10/23/2020; all other communication done in person. Signed by the Administrator. Interview on 11/4/2020 at 2:27 p.m. with the Administrator revealed she reviewed each of the facility audit reports and reports to the Medical Director and Interdisciplinary Team during QAPI meetings.

Based on record review, family and staff interviews and review of facility's policy titled Care of a Resident with [MEDICAL CONDITION] and [MEDICAL TREATMENT] Service Agreement, the facility failed to ensure [MEDICAL TREATMENT] services were initiated timely upon admission; and failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] center for one resident (R) (#10) reviewed of six residents receiving [MEDICAL TREATMENT]. Actual harm was identified when R#10 was hosptalized on [DATE] for complications related to not receiving [MEDICAL TREATMENT]. Findings include: Review of the facility's policy titled Care of a Resident with [MEDICAL CONDITION] revised date of September 2010, revealed the policy statement as residents with [MEDICAL CONDITIONS] will be cared for according to currently recognized standards of care. Number 2: Education and training of staff include: 2b. The type of assessment data that is to be gathered about the resident's condition on a daily basis or per shift basis; 2g. The care of grafts and fistulas. Number 4: Agreements between the facility and the contracted [MEDICAL CONDITION] facility include all aspects of how the resident's care will be managed: 4a. How the care plan will be developed and implemented. 4b. How information will be exchanged between the facilities. Number 5: The resident's comprehensive care plan will reflect the resident's needs related to [MEDICAL CONDITION]/[MEDICAL TREATMENT] care. Review of [MEDICAL TREATMENT] Services Agreement, with effective date 10/1/2018 and automatically renews each year on the anniversary date, unless terminated by either party. Section 1.3 Scheduling revealed Provider shall be prepared to accept a patient for services at Provider's site within one (1) working day of receiving a telephone request from the Center staff member. Section 1.4 Care Plan revealed (a) when a center resident with [MEDICAL CONDITION] requires [MEDICAL TREATMENT], the Provider and the Center shall jointly develop and agree upon the resident's care plan appropriate for management of end stage [MEDICAL CONDITION]. Review of the clinical record for R#10 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Hospital Records prior to admission revealed the following: * The Nephrology physician progress notes [REDACTED]. HD on MWF (Monday, Wednesday, and Friday), needs HD arranged but awaiting final disposition. * Review of hospital discharge paperwork printed 6/25/2020 at 3:15 p.m. by Admissions Director RRRR, revealed R#10 was discharged from the hospital with [MEDICAL TREATMENT] Catheter (Vascath - Central Venous Catheter inserted into a vein located in either the neck or the groin) to the right side of neck placed on 6/1/2020. Review of EMPC-Nursing Comprehensive Assessment V.2 (facility admission assessment) dated 6/25/2020, revealed page 1 General Reason for Note a. Admission. On page 6, section G1c.7, [MEDICAL TREATMENT] was not indicated on the assessment. On page 9, section C. Devices and Care Management, A1. devices in use does not have yes or no response marked. Section C. Devices and Treatments, B1. reveals 1. Enteral feeding and no response marked for 5. Other (device/treatment). There is no documentation for sections B1a through B2 under Devices and Treatments. Assessment was completed by Licensed Practical Nurse (LPN) VV. Review of the physician's orders [REDACTED]. Review of care plan for R #10, initiated 6/25/2020, revealed resident did not have a care plan problem to include the need for [MEDICAL TREATMENT], related to [DIAGNOSES REDACTED]. Review of R#10's [MEDICAL TREATMENT] Communication Records revealed there is no evidence that resident received [MEDICAL TREATMENT] treatments on scheduled days of 6/26/2020 and 6/29/2020 (the Friday and Monday after admission to the facility, when the resident should have been scheduled for [MEDICAL TREATMENT]). R#10 was sent back to the hospital on [DATE]. Review of the Hospital Records for admitted [DATE] revealed R#10 was hospitalized with the following concerns: [MEDICAL CONDITION]: suspected uremia (a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys). R#10's BUN (blood urea nitrogen level was 141; normal range 8-20 mg/dl (milligrams / decaliter). [MEDICAL CONDITION] (potassium level was 5.9; normal range 3.5 - 5.1). [MEDICAL CONDITION] of CKD ([MEDICAL CONDITION]): R#10 received one unit of packed red blood cells on 7/3/2020. Systolic [MEDICAL CONDITIONS] and acute on chronic [MEDICAL CONDITION]. The chest X-ray dated 7/1/2020 revealed cardiomegaly with some degree of fluid volume overload. The resident started receiving [MEDICAL TREATMENT] again on 7/2/2020 and was started on [MEDICAL CONDITION] (oxygen delivered under positive pressure). The resident was discharged back to the facility on [DATE]. Review of Physician Encounter Note dated 7/22/2020 at 11:32 a.m. revealed resident was readmitted to hospital on [DATE] due to shortness of breath. Patient was supposed to be on [MEDICAL TREATMENT] but had not received a treatment since her arrival to Renaissance. The Admission Minimum Data Set ((MDS) dated [DATE] for R#10 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating no cognitive impairment. Section O revealed resident was receiving [MEDICAL TREATMENT]. Review of the physician's orders [REDACTED]. Review of the [MEDICAL TREATMENT] Communication Records for R#10 revealed she was not consistently assessed post [MEDICAL TREATMENT] treatment by the facility nurse, and the communication between the facility and the [MEDICAL TREATMENT] center was not consistently maintained. Review of [MEDICAL TREATMENT] Communication Records since readmission on 7/21/2020 revealed missing records for 7/27/2020, 7/31/2020, 8/3/2020, 8/5/2020, 8/7/2020, 8/17/2020, 8/21/2020, 8/28/2020, 8/31/2020, 9/2/2020, 9/4/2020, 9/9/2020, 9/11/2020, 9/14/2020, 9/21/2020, and 10/2/2020. Review of the [MEDICAL TREATMENT] Communication Record for months July through October 2020 revealed the following: 7/24/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 7/29/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 8/10/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 8/11/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 8/14/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 8/19/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 8/24/2020-The section of the form to be completed by [MEDICAL TREATMENT] Center was left blank. 8/26/2020-The section of the form to be completed by [MEDICAL TREATMENT] Center was left blank. 9/2/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 9/7/2020-The section of the form to be completed by Licensed Nurse prior to [MEDICAL TREATMENT] treatment and post-[MEDICAL TREATMENT] was left blank. 9/16/2020-The section of the form to be completed by Licensed Nurse prior to [MEDICAL TREATMENT] treatment and post-[MEDICAL TREATMENT] was left blank. 9/18/2020-The section of the form to be completed by [MEDICAL TREATMENT] Center and Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 9/23/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 9/25/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. 9/30/2020-The section of the form to be completed by Licensed Nurse post-[MEDICAL TREATMENT] was left blank. Interview on 10/8/2020 at 9:32 a.m. with family of R#10 revealed that her mother was admitted to the facility in June 2020 and went back to hospital after one week at the facility. She stated that her mother did not receive [MEDICAL TREATMENT] treatments the first week she was at facility, despite telling the facility that she had [MEDICAL TREATMENT] three times per week. She further stated that R#10 was readmitted to the hospital on [DATE]. Interview on 10/8/2020 at 10:58 a.m. with Licensed Practical Nurse (LPN) MMM revealed she has been employed at the facility for four months. She stated that she remembers that R#10 was very receptive to care being provided. She stated that resident had [MEDICAL TREATMENT] but could not remember what her scheduled days were. She further stated that resident never refused [MEDICAL TREATMENT] treatments, to her knowledge. Interview on 10/21/2020 at 1:10 p.m. with [MEDICAL TREATMENT] Registered Nurse (RN) MM, stated she is familiar with R#10. She stated she has been coming to [MEDICAL TREATMENT] since 7/22/2020. She stated the resident did miss one [MEDICAL TREATMENT] visit on 9/28/2020 but has not missed any others. Interview on 10/22/2020 at 1:45 p.m. with the Administrator revealed that she has been employed at the facility since 8/3/2020. She stated that she could only find a few [MEDICAL TREATMENT] Communication forms for R#10. During further interview, she stated that she recognized the process was not being done consistently. Interview on 10/23/2020 at 9:40 a.m. with Licensed Practical Nurse (LPN) JJJ revealed that she has been employed at facility for two months. She stated that each [MEDICAL TREATMENT] resident has a binder which contains the resident face sheet, Physician Orders, a mask, and daily [MEDICAL TREATMENT] Communication Record. She stated that she does her assessment of resident (obtaining VS (vital signs), assessing shunt site, and completing communication form) about 30 minutes before resident is scheduled to be picked up. Interview on 10/23/2020 at 3:21 p.m. with LPN VV revealed she has been employed at the facility since April 2020. She stated that when new residents are admitted , the admitting nurse will complete the Comprehensive Assessment in the electronic medical record (EMR). She stated this assessment was a head to toe assessment, where the nurse should document the assessment of the resident's body systems. She stated that she remembers completing the Admission Assessment for R#10. During further interview, she stated that the resident had a [MEDICAL TREATMENT] catheter in her chest on admission but cannot remember placement site. LPN VV stated that she thought she had put [MEDICAL TREATMENT] orders in the EMR, but during review of the June Physician Orders, she was unable to locate an order for [REDACTED]. Interview on 10/28/2020 at 1:48 p.m. with Admissions Director RRRR revealed that it is the responsibility of the hospital Social Worker or Case Manager to make sure residents have been scheduled for days and chair times for outpatient [MEDICAL TREATMENT]. She stated that the hospital failed to finalize R#10's [MEDICAL TREATMENT] services and the facility was not aware until the family called to inform her that R#10 was not getting her [MEDICAL TREATMENT]. During further interview, she stated she is not sure why nursing missed that R#10 was supposed to be going to [MEDICAL TREATMENT] and stated that she would have been more than happy to set up transportation if they would have asked her. Interview on 10/29/2020 at 11:00 a.m. with Director of Nursing (DON) revealed she has been employed at the facility since 8/3/2020. She stated that her expectation of the nurses for new admissions is to read through all the hospital paperwork, reading history and physical, reading course of treatments, picking out the most relevant information, including medication list and any specialized care, such as tube feedings and wound care. She further stated that the nurses are expected to complete a head to toe assessment on each new admission and document findings in EMR. She stated that she would expect the nurses to notify the hospital or Physician for anything out of the normal or to obtain clarification. During further interview, she stated that she would expect the nurses to question if a resident has a [MEDICAL TREATMENT] catheter, why there are no orders or information regarding [MEDICAL TREATMENT]. She stated that R#10 was admitted prior to her arrival as the DON and she had no knowledge that R#10 missed [MEDICAL TREATMENT] during her first admission to the facility. Interview on 10/30/2020 at 1:03 p.m. with Medical Director (MD) revealed that he has been at the facility since August 2019. He stated that he attempts to see new admissions within 48-72 hours. He stated that he reviews medical records, where the resident comes from, performs an assessment, and evaluates the resident's condition. He stated that he would expect staff to acknowledge when a resident is admitted with any type of device. During further interview he stated he was unaware that the resident did not receive [MEDICAL TREATMENT] treatments on her first admission.